BlueCross BlueShield of Western New York Formulary 1 Please bring this guide with you the next time you visit your doctor.

If you have questions about your prescription drug benefit, visit the Pharmacy Services section of the BlueCross BlueShield web site at www.bcbswny.com. CRP2107_009678.1 MG009678A (Revise Date 07/01/2021)

A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield are registered trademarks of the BlueCross BlueShield Association. Inside front cover TABLE OF CONTENTS

Introduction ...... iii

Understanding the symbols used throughout this book ...... iii Using this formulary book to help contain costs . iv Save Money on Your Prescription Drugs...... iv Finding Medications in the Guide ...... v

Section 1 — Therapeutic Drug Categories...... 1

Section II — Index...... 8

ii The BlueCross BlueShield of Western New York Formulary 1 is a list of drugs to help guide physicians and pharmacists to select the medication that provides the appropriate treatment for the best price.

Introduction

BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’ health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.

Understanding the symbols used throughout this book Throughout this book, you will see certain symbols that indicate a management program is in place for selected medications. The symbols are as follows:

Key

P = A step edit applies to this drug. Step therapy means that in order to receive the medication with a step edit, a preferred medication must be tried first. z = Specific quantity limits apply. Quantity limits are in place to ensure members receive the appropriate amount of medication not to exceed the maximum allowable daily dosage of medication.  = Prior authorization required. Prior authorization (also referred to as coverage review) means that a healthcare professional must submit clinical documentation to obtain approval for a member to receive the medication. Prior authorizations ensure medications are being used appropriately. u = Included in tablet-splitting program. The medication can be cut in half to obtain the daily dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month copay. + = Access restricted to specialty pharmacy. Medications must be obtained through a specialty pharmacy.  = Affordable Care Act (ACA) Preventive Drug. The medication is included on the ACA Preventive Drug List.

iii Using this formulary book to help contain costs

Many employers, benefit sponsors, and individuals may use the formulary to help manage the overall cost of providing prescription drug benefits. The formulary offers a wide range of outpatient medications.

Because there are over 40,000 Food and Drug Administration (FDA)-approved prescription drugs on the market, not all tier 3 drugs can be listed in this formulary guide. We have included in this printed formulary guide the drugs that are most commonly prescribed for our members. If you have any questions regarding coverage of a drug, please call the customer service number on your card.

Save Money on Your Prescription Drugs Here’s what you can do to save money:

1. Bring this member guide to your doctor and review the cost-saving information below.

2. Ask your doctor whether a drug listed in this guide is right for you.*

Tier 3 Tier 1 Tier 2

Lowest cost to you Highest cost to you

The amount you pay for a drug is determined by which medication you purchase and to what tier it is assigned. Some drug plans exclude certain drugs or classes of drugs from coverage. Please check your contract or other plan documents if you have a question about your specific drug coverage.

Please refer to your plan documents to confirm your cost share for diabetic drugs and supplies. Cost share may vary by plan. Affordable Care Act (ACA) Preventive Drug List The Affordable Care Act (ACA) Preventive Drug List consists of medications that may be covered at $0. They are not subject to any annual deductibles, coinsurance, or copayments. Please refer to your plan documents to confirm if the ACA Preventive Drug List applies to you.

We’ve noted any drugs on the ACA Preventive Drug List within this guide. Please consult the key on page iii. This list is reviewed periodically and is subject to change.

The presence of a drug on this list does not guarantee coverage. Drugs on this list may require prior authorization, step-edits, and quantity limits. Restrictions may apply to certain brand-name ACA medications with generic equivalents. Other restrictions may apply according to U.S. Preventive Services Task Force (USPSTF) recommendations, which define ACA coverage requirements. These restrictions may be based on age, dose, diagnosis, and others as recommended by USPSTF. Both prescription and over-the-counter (OTC) products are eligible to be covered when prescribed by a licensed health care provider and require a valid prescription.

* Some plan designs require that you use a Tier 1 generic drug if a generic is available.

Disclaimer: The BlueCross BlueShield of Western New York Medication Guide is subject to change, as we regularly review medications and existing therapies for inclusion in the BlueCross BlueShield of Western New York Formulary 1. The tier that a medication is currently in may change during the effective dates of the guides due to generic availability.

iv Contraceptive Coverage under New York Insurance Law Contraceptives (for members whose benefits align with contraceptive coverage requirements under New York Insurance Law): All tier 1 contraceptives are covered at a $0 copayment. Brand-name contraceptives without a generic equivalent are covered at a $0 copayment. Brand-name contraceptives with a generic equivalent are covered at the copayment based on your plan design unless deemed medically necessary by the prescriber. The prescriber must designate “DAW” (Dispense as Written) on the prescription in order for the brand-name contraceptive with a generic equivalent to be considered medically necessary and covered at a $0 copayment. Both prescription and over-the-counter (OTC) products are covered only when prescribed by a licensed health care provider and require a valid prescription. Please refer to your plan documents to confirm your cost share for contraceptives. Cost share may vary by plan.

Contraceptives may include implantable rods, intrauterine devices (IUD), shots/injections, oral contraceptives, patches, vaginal contraceptive rings, diaphragms, sponges, cervical caps, female condoms, spermicides, and emergency contraceptives. Please see the “Women’s Health” section of this guide for specific product examples. Finding Medications in the Guide This guide lists medications two different ways:

Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis)

Locate a category and drug on the guide and you will see the tier and copayment for that drug—Tier 1, Tier 2 or Tier 3—which determines your copayment. To determine if a drug is a generic or brand-name medication, look at the name of the drug. Generic medications are lower case (e.g., amoxicillin), and brand-name medications are capitalized (e.g., Advair).

Section 2: Alphabetically by drug name. Use this list to find your drug.

Questions? Please call Pharmacy Services at 1 800 939-3751 if you have any questions about the BlueCross BlueShield of Western New York Formulary 1. For the most up-to-date version of the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com.

v Section I — Therapeutic drug categories

TIER TIER TIER TIER z Allergy/Cough & Cold z tolterodine ER 1 Cancer Drugs  Ayvakit 3 z z trospium 1  Balversa 3 Antihistamines & Decongestants z Alkylating Agents z Braftovi 3 brompheniramine/phenylephrine 1 trospium ER 1 cyclophosphamide 1  z z Brukinsa 3 brompheniramine/pseudoephedrine 1 Myrbetriq 2 Alkeran 2  z z Calquence 3 z carbinoxamine 1 Toviaz 2 CeeNu 2  P z z Copiktra 3 cetirizine 1 P Detrol 3 Emcyt 2  z + z Daurismo 3 clemastine 1 P Detrol LA 3 Hexalen 2  z + z Erleada 3 cyproheptadine 1 P Ditropan XL 3 Leukeran 2  z Fotivda 3 dexchlorpheniramine 1 P Enablex 3 Myleran 2  z  Gavreto 3 diphenhydramine 1 P Gelnique 3 Antimetabolites z + Gleevec 3 hydroxyzine HCl 1 z Oxytrol 3 + capecitabine 1 zP P + Idhifa 3 hydroxyzine pamoate 1 z Sanctura 3 mercaptopurine 1 z P + Inrebic 3 z levocetirizine 1 z Sanctura XR 3 methotrexate 1 z P + Kesimpta 3 loratadine 1 Cholinergic Agents Purixan 2 z + Kisqali 3 Urecholine 3 + z Inqovi 3 zP loratadine-D 1  + Kisqali Femara Co-Pack 3 + Onureg 3 z pseudoephedrine 1 Miscellaneous   Koselugo 3 Trexall 3 z Semprex-D 2 z Gemtesa 3 + Lorbrena 3 z P z Xatmep 3 z Clarinex-D 3 z Jynarque 3   Mektovi 3  Hormones z z desloratadine 3 + Nerlynx 3 Blood anastrozole 1 z z Grastek 3   Orgovyx 3  bicalutamide 1 z z Odactra 3 Anticoagulants/antithrombotics  Pemazyre 3  exemestane 1 z z Oralair 3 anagrelide 1  + Piqray 3  flutamide 1 z z Palforzia 3  aspirin 81mg OTC 1  Qinlock 3  letrozole 1 z z Ragwitek 3 aspirin 325mg OTC 1  + Retevmo 3   leuprolide 1 z Expectorant & Cough Products aspirin/dipyridamole 1  + Rozlytrek 3 megestrol 1 z benzonatate 1 clopidogrel 1 + Rubraca 3 z raloxifene 1 z guaifenesin/codeine 1 dipyridamole 1   Rydapt 3 tamoxifen 1 z hydrocodone/chlorpheniramine 1 enoxaparin 1  + Tabrecta 3 Fareston 2 z fondaparinux sodium 1 + Talzenna 3 hydrocodone/homatropine 1 + z Nubeqa 3 z promethazine/codeine 1 heparin 1  + Tarceva 3 jantoven 1 Miscellaneous z Tazverik 3 promethazine/DM 1 z  prasugrel 1 + abiraterone acetate 1 + Temodar 3 promethazine/phenylephrine/codeine 1 z z ticlopidine 1 + erlotinib 1  Tepmetko 3 pseudoephedrine/codeine 1 z warfarin 1 etoposide 1  Tibsovo 3 Cardec/DM 3 z z Brilinta 2 + everolimus (generic Afinitor) 1  Tukysa 3 Guaifenesin DM 3 z Coumadin 2 hydroxyurea 1  Turalio 3 Hycodan 3 z z Eliquis 2 + imatinib 1 + Tykerb 3 Rondec DM/TR 3 + z lapatinib 1 Ukoniq 3 Vituz 3 Fragminxx 2   Xarelto 2 nilutamide 1 z Venclexta 3 Mucolytic Agents  z Zontivity 2 + temozolomide 1 + z Vitrakvi 3 acetylcysteine inh soln. 1 z  Bevyxxa 3 + Alecensa 2 + z Vizimpro 3 z  Nasal Medications z + Arcalyst 2 + Xgeva 3 Durlaza 3 z azelastine nasal spray 1 + Bosulif 2 z Xospata 3 Innohep 3 z  budesonide nasal spray 1 z + Cabometyx 2 z Xpovio 3 Pradaxa 3 z  Clarispray 1 z  Caprelsa 2 + z Yonsa 3 Savaysa 3 z  Flonase Allergy Relief 1 + Cometriq 2 z Zejula 3 Other Blood Modifiers z  Flonase Sensimist 1 + Cotellic 2 + z Zytiga 3 cilostazol 1 z P z fluticasone nasal spray 1 + Erivedge 2 Rexinoids + deferasirox 1 + z Farydak 2 ipratropium nasal spray 1  + bexarotene 1 z pentoxifylline 1 + z Gilotrif 2 + Targretin gel 3 mometasone nasal spray 1 z   z Nasacort Allergy 24HR 1  trientine 1 + Hycamtin capsule 2 + z Actimmune 2 z Diabetes Rhinocort Allergy 1  + Ibrance 2 z triamcinolone nasal spray 1 + Aranesp 2  Iclusig 2 Please refer to your plan documents to confirm your cost z Atrovent Nasal Spray 3 + Fulphila 2  Imbruvica 2 share for diabetic drugs. Cost share may vary by plan. z + Leukine 2 + z Inlyta 2 P Beconase AQ 3  Antidiabetic Agents, Injectable Miacalcin inj. 2 + Intron A 2 Dymista 3 z Basaglar 2 z + Neulasta 2 + Iressa 2 flunisolide nasal spray 3 z z Bydureon 2 z + z Promacta 2 + Jakafi 2 P Nasacort AQ 3  z z Byetta 2 z + Retacrit 2 + Lenvima 2 P Omnaris 3 z Humalog insulin 2 z + z Revlimid 2 + Lonsurf 2 P Qnasl 3  z Humulin (all types) 2 z Strensiq 2 + Lynparza 2  Xhance 3  Lantus 2 z + Zarxio 2 Lysodren 2 P Zetonna 3 Matulane 2 Lyumjev 2 Alzheimer Agents + Alprolix 3 + z Mekinist 2 z Ozempic 2 z Cablivi 3  z z donepezil 1  Mesnex 2 Soliqua 2 deferiprone 3 z z Symlin 2 ergoloid mesylates 1  + Nexavar 2  + z Doptelet 3 z Toujeo 2 z galantamine 1  + Ninlaro 2 + Eloctate 3 z z Trulicity 2 z + Odomzo 2 galantamine ER 1 + z Endari 3 z z Victoza 2 z memantine 1  + Pomalyst 2 z + Epogen 3 + z Sprycel 2 P Admelog 3 memantine ER 1  z Adlyxin 3 z + Exjade 3 + Stivarga 2 P rivastigmine 1 z Apidra 3 Ferriprox 3 + Sutent 2 P z rivastigmine patch 1  z Fiasp 3 + Granix 3  Sylatron 2 P z Namzaric 2  z Insulin Lispro 3 + Hemlibra 3  Synribo 2 P  z Levemir 3 Bladder/Kidney + Jadenu 3 + Tafinlar 2 P z Novolin 3 Acidifiers + Jivi 3 + Tagrisso 2 P Mircera 3 + z Tasigna 2 P Novolog 3 K-Phos 2   Semglee 3 + z Mulpleta 3 + Thalomid 2 P Alkalinizers  z z Tanzeum 3 + Valchlor 2 P potassium citrate 1 + Neupogen 3 z Tresiba 3 + Verzenio 2 P Oracit 3 + Nivestym 3 z z Xultophy 3 + Votrient 2 Analgesics + Nyvepria 3 z P + Xalkori 2 Antidiabetic Agents, Glucose Elevating agents phenazopyridine 1 Omontys 3 z  + Xtandi 2 acarbose 1 Anticholinergics + z Oxbryta 3 z  + Zelboraf 2 chlorpropamide 1 z oxybutynin 1 + Procrit 3 z z  + Zolinza 2 glimepiride 1 z z Tavalisse 3 z oxybutynin ER 1  + Zydelig 2 glipizide 1 z + Udenyca 3 z z Oxytrol for Women 1 P + Zykadia 2 glipizide ER 1 z z z solifenacin 1 +P Ziextenzo 3 + Afinitor 3 glipizide/metformin 1 z z zP tolterodine 1 Zontivity 3 + Alunbrig 3 glyburide 1 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

1 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER glyburide micronized 1 Pazeo 3 Prostaglandin Analogues/Prostamines colesevelam 1 metformin 1 Zaditor 3 bimatoprost 0.03% 1 z ezetimibe 1 z metformin ER (generic Glucophage XR) 1 Zerviate 3 latanoprost 1 fenofibrate (generic) 1 z metformin/glyburide 1 fenofibric acid, tab 1 Anti-infective Agents Lumigan 0.01% 2 metformin solution 1 bacitracin ophth 1 gemfibrozil 1 z Xelpros 2 zu nateglinide 1 bacitracin/polymyxin 1  lovastatin 1 z pioglitazone/metformin 1 ciprofloxacin ophth 1 P Izba 3 niacin ER 1 z repaglinide 1 erythromycin ophth 1 P Rescula 3 P niacin IR 500mg tablet 1 tolazamide 1 niacin (OTC) 1 gatifloxacin 1 P Travatan Z 3 tolbutamide 1 travoprost (generic Travatan Z) 3 z niacin/simvastatin 1 z gentamicin ophth 1 Avandamet 2 moxifloxacin 0.5% (generic Vigamox) 1 Vyzulta 3 zu pravastatin 1 z P z  Avandaryl 2 neomycin/bacitracin/poly B 1  rosuvastatin 1 z P Xalatan 3 zu Avandia 2 ofloxacin ophth 1  simvastatin 1 z Duetact 2 Zioptan 3 polymyxin B/TMP 1 P Advicor 2 z Farxiga 2 Sympathomimetics Colestid 2 GlucaGen 2 sulfacetamide 10% 1 brimonidine 1 tobramycin soln 1 Fenofibrate 50mg, 150mg cap (brand) 2 Glucagon 2 Alphagan P 0.1% 2 + z Kynamro 2 Besivance 2  z Glyxambi 2  Upneeq 3 Lipofen 2 z Invokamet 2 Moxeza 2 Vasoconstrictors Livalo 2 z Invokamet XR 2 Tobrex ointment 2  z naphazoline 1  Praluent 2 z Invokana 2 Azasite 3 phenylephrine ophth 1 z Repatha 2 z Ciloxan 3  Janumet 2 Gout Vascepa 2 z Janumet XR 2 Tobrex solution 3 z Altoprev 3 z Januvia 2 Anti-inflammatory allopurinol 1 zu  Crestor 3 z Jardiance 2 fluorometholone ophth 1 colchicine (generic Colcrys) 1 z Epanova 3 Jentadueto 2 loteprednol 1 colchicine/probenecid 1 z  Ezallor 3 z Jentadueto XR 2 loteprednol etabonate susp 1 z febuxostat 1 z ezetimibe-simvastatin 3 Juvisync 2 prednisolone acetate 1 probenecid 1 Fenofibrate 160mg tab (brand) 3 z Rybelsus 2 prednisolone sod phosphate 1 z Mitigare 2 z fenofibric acid, capsule DR 3 z Synjardy 2 FML Forte 2 z Duzallo 3 z fluvastatin 3 z Synjardy XR 2 FML S.O.P. 2   z z Gloperba 3 + Juxtapid 3 Tradjenta 2 Lotemax ointment 2 zu z  Lescol 3 z Trijardy XR 2 Lotemax SM 2  Zurampic 3 z  Lescol XL 3 z Xigduo XR 2 Pred Mild 2 Heart zu Lipitor 3 Afrezza 3 Flarex 3 z  Angiotensin Converting Enzyme Inhibitors  Nexlizet 3 Baqsimi 3 Lotemax gel 3 z benazepril 1  Nexletol 3 Fortamet 3 Maxidex 3 z Nikita 3 Pz captopril 1 P Glumetza 3 Anti-inflammatory/Anti-infective combinations z omega-3 acid ethyl esters 3 Kazano 3 enalapril 1 P dexameth/neomycin/poly B 1 fosinopril 1 z Omtryg 3 P Kombiglyze XR 3 neomycin/bacitracin/poly B/HC 1 zu Pravachol 3 z metformin ER (not generic Glucophage XR) 3 lisinopril 1  P sulfacetamide/prednisolone ophth 1 moexipril 1 zu Zocor 3 miglitol 3 tobramycin/dexameth 1 z  perindopril 1  Zypitamag 3 P Nesina 3 Tobradex ointment 2 Beta Blockers Onglyza 3 quinapril 1 P Tobradex ST 2 ramipril 1 acebutolol 1 P Oseni 3 Zylet 2 atenolol 1 z Qtern 3 trandolapril 1 Maxitrol ophth 3 z Epaned 3 betaxolol 1 repaglinide/metformin 3 Pred-G 3  z Qbrelis 3 bisoprolol 1 z Segluromet 3 Antiviral  Angiotensin II Antagonists carvedilol 1 z Steglatro 3 z famciclovir ophth 1 z Steglujan 3 z eprosartan 600mg 1 carvedilol ER 1 trifluridine 1 z irbesartan 1 labetalol 1 Diabetic Supplies Beta-Blockers (Eye) z losartan 1 metoprolol 1 Please refer to your plan documents to confirm your betaxolol HCl 1 z olmesartan 1 metoprolol ER 1 cost share for diabetic supplies. Cost share may vary carteolol 1 z telmisartan 1 metoprolol/HCTZ 1 z by plan. Test strips other than OneTouch require levobunolol 1 valsartan 1 nadolol 1 metipranolol 1 z Edarbi 3 prior authorization. pindolol 1 timolol 1 z Prexxartan 3 propranolol 1 OneTouch Test Strips P Betoptic-S 2 Anti-Adrenergic Blockers Centrally Acting timolol 1 P Accu-Chek Istalol 3 clonidine, oral, patch 1 Bystolic 2 z P Ascensia Breeze Carbonic Anhydrase Inhibitors + droxidopa 1 Innopran XL 2 P Contour brinzolamide 1 guanfacine 1 Hemangeol 3 methyldopa 1 P Freestyle dorzolamide 2% eye drops 1 Calcium Channel Blockers dorzolamide/timolol eye drops 1 midodrine 1 P Precision amlodipine 1 TRUEtest Azopt 3 phenoxybenzamine 1 cartia XT 1 P + z Northera 3 TRUEtrack Miotics  diltia XT 1 P pilocarpine 1 Anti-Adrenergic Blockers Peripheral diltiazem 1 Ear Phospholine Iodide 2 doxazosin 1 diltiazem CD/SR/ER/XR 1 Anti-infective Agents Miscellaneous prazosin 1 felodipine ER 1 acetic acid otic 1 Combigan 2 terazosin 1 isradipine 1 acetic acid/aluminum acetate 1 Cystaran 2 Cardura XL 3 nicardipine 1 ciprofloxacin otic 1 z Restasis 2 Antiarrhythmics nifediac CC 1 amiodarone 1 ofloxacin otic 1 z Xiidra 2 nifedical XL 1 Domeboro 3 digoxin 1 nifedipine 1 z Cequa 3 disopyramide 1 Xtoro 3 Cystadrops 3 nifedipine SR 1  dofetilide 1 nimodipine 1 Anti-infective/Anti-inflammatory combinations + z Oxervate 3 acetic acid HC otic 1  flecainide 1 nisoldipine 1 ciprofloxacin/dexamethasone 1 P Rhopressa 3 mexiletine 1 verapamil/SR 1 z Rocklatan 3 procainamide 1 z neomycin/polymyxin/HC otic 1  P Conjupri 3 Cipro HC 3 Mydriatics propafenone 1 Dynacirc/CR 3 atropine sulfate ophth 1 propafenone SR 1 P Katerzia 3 Eye homatropine 1 quinidine gluconate 1 z Nymalize 3 Antiallergy Agents (Eye) tropicamide 1 quinidine sulfate SR 1 Combination Anti-Hypertensive azelastine ophth 1 NSAIDs sotalol 1 aliskiren 1 Lanoxin 2 cromolyn ophth 1 bromfenac 1 z amlodipine/atorvastatin 1 olopatadine 0.2% drop 1 diclofenac 1 Multaq 2 olopatadine ophth 1 flurbiprofen ophth 1 Norpace CR 3 amlodipine/benazepril 1 Alomide 2 Ilevro 2 Antilipidemics z amlodipine/valsartan 1 zu amlodipine/valsartan/HCTZ 1 Alrex 2 Nevanac 2  atorvastatin calcium 1 Bepreve 2 Prolensa 2 cholestyramine 1 atenolol/chlorthalidone 1 ketotifen opthalmic solution 3 Acular PF 3 colestipol 1 benazepril/HCTZ 1

KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

2 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER

bisoprolol/HCTZ 1 + veletri 3 Immunosuppressants Luzu 3 z z candesartan/HCTZ 1 +P Ventavis 3 azathioprine 1 Oravig 3 z captopril/HCTZ 1 Vasodilators cyclosporine 1 P Oxistat cream 3 gengraf 1 z enalapril/HCTZ 1 hydralazine 1 P Tolsura 3 fosinopril/HCTZ 1 isosorbide dinitrate 1 mycophenolate mofetil 1 Antimalarials z irbesartan/HCTZ 1 isosorbide mononitrate 1 mycophenolic acid 1 atovaquone/proguanil HCl 1 lisinopril/HCTZ 1 isosorbide mononitrate SA 1 sirolimus 1 chloroquine phosphate 1 isoxsuprine 1 tacrolimus 1 z losartan/HCTZ 1 mefloquine 1 minoxidil oral 1 Astagraf XL 2 pyrimethamine 1 methyldopa/HCTZ 1 nitroglycerin pumpspray 1 Cellcept 2 metoprolol/HCTZ 1 Primaquine 2 nitroglycerin SR 1 Envarsus XR 2 quinine sulfate 3 z olmesartan/amlodipine 1 nitroglycerin transdermal patch 1 Neoral 2 Antituberculosis z olmesartan/amlodipine/HCTZ 1 Dilatrate SR 2 Prograf 2 ethambutol 1 z olmesartan/HCTZ 1 Nitrostat SL tabs 2 Sandimmune 2 isoniazid 1 propranolol/HCTZ 1 Gonitro 3 Zortress 2 pyrazinamide 1 Minitran 3 quinapril/HCTZ 1 z Lupkynis 3 rifabutin 1 NitroDur patches 3  z telmisartan/HCTZ 1 Infection rifampin 1 z valsartan/HCTZ 1 HIV - Antivirals Antibacterial Agents/Antibiotics Coartem 2 z Byvalson 2 Non-Nucleoside Reverse Transcriptase Inhibitor amoxicillin 1 Rifater 2 z Rifamate 3 P Tekturna HCT 2 efavirenz 1 amoxicillin-clavulanate ER 1 z efavirenz/emtricit/tenofovr df 1 Sirturo 3 P Amturnide 3 ampicillin 1 z Edarbyclor 3 Edurant 2 azithromycin suspension 1 Antivirals Intelence 2 azithromycin tablets 1 z acyclovir oral 1 z Prestalia 3 Rescriptor 2 z cefaclor 1 amantadine 1 P Tekturna 3 Viramune, XR 2 z famciclovir 1 z Atripla 3 cefadroxil 1 telmisartan/amlodipine 3 cefdinir 1 ganciclovir 1 trandolapril/verapamil 3 Nucleoside Analog Reverse Transcriptase Inhibitor cefpodoxime 1 + moderiba 1 Diuretics Combination cefprozil 1 oseltamivir 1 acetazolamide 1 abacavir/lamivudine/zidovudine 1 cefuroxime 1 + ribapak 1 acetazolamide ER 1 efavirenz/lamivu/tenofovr diop 1  cephalexin 1 + ribasphere 1 amiloride 1 emtricitabine/tenofovir disop 1  ciprofloxacin 1 + ribavirin 1 amiloride/HCTZ 1 lamivudine/zidovudine 1 clarithromycin susp 1 rimantadine 1 bumetanide 1  tenofovir 300mg 1 clarithromycin tabs 1 z valacyclovir 1 chlorothiazide 1 Biktarvy 2 clindamycin 1 valganciclovir tablets 1 chlorthalidone 1 z Cimduo 2 dicloxacillin 1 + Epclusa 2 furosemide 1 Complera 2 doxycycline 1 Epivir-HBV solution 2 hydrochlorothiazide 1 ery-tab 250mg, 333mg 1 + z Harvoni 2  Descovy 2  indapamide 1 Dutrebis 2 erythromycin base 1 z Hepsera 2 methazolamide 1 z Odefsey 2 erythromycin DR 1 + Mavyret 2 methyclothiazide 1 erythromycin ethylsuccinate 1 + Pegasys 2 metolazone 1 Stribild 2  Triumeq 2 erythromycin stearate 1 Relenza 2 spironolactone 1 erythromycin/sulfisoxazole 1 z Viread 150mg, 200mg, 250mg, + Sovaldi 2 spironolactone/HCTZ 1  levofloxacin 1 40mg/scoop powder 2 + Victrelis 2 torsemide 1 minocycline 1 z Symfi 3 +P Viekira 2 triamterene/HCTZ 1 nitrofurantoin 1 Baraclude solution 3 Symfi Lo 3 z Carospir 3 ofloxacin 1 entecavir tablets 3 Miscellaneous Cardiovascular Agents Truvada 3 penicillin VK 1 z  +P Ledipasvir/Sofosbuvir 3 z eplerenone 1 Nucleoside Reverse Transcriptase Inhibitors sulfamethoxazole/trimethoprim 1 + Peg-Intron 3 z abacavir-lamivudine 1 P + icatibant 1 tetracycline 1 z Prevymis tablets 3 midodrine 1 didanosine 1 Ketek 2  + Rebetol 3 ranolazine ER 1 emtricitabine 1 Zmax 2 + Ribatab 3 z Baxdela 3  + tolvaptan 1 lamivudine tabs 1 z Sitavig 3 z Biaxin XL 3 P + Berinert 2 stavudine 1 + z Sofosbuvir/Velpatasvir 3 z cefixime 3 P + Cinryze 2 zidovudine 1 z Tyzeka 3 z Entresto 2 Emtriva solution 2 Ceftin 3 valganciclovir solution 3 z Cleocin 3 + Ruconest 2 Epivir solution 2 z Valtrex 3 z z doxycycline hyclate 50mg, 75mg, 150mg tab 3 + Samsca 15mg 2 Videx 2 z Vemlidy 3 z Consensi 3 Ziagen 2 erythromycin estolate 3 + z Vosevi 3 P erythromycin suspension 3  z Corlanor 3 Other z Xofluza 3 z Factive 3 z + Firazyr 3 Fuzeon 2 +P Zepatier 3 z z Lymepak 3 + Haegarda 3 Genvoya 2 Other Anti-Infectives z Orladeyo 3 Minocin 3 atovaquone 1  Isentress 2 moxifloxacin 3 Ranexa 3 Juluca 2 dapsone tablets 1 z Noroxin 3 + Samsca 30mg 3 Selzentry 2 z linezolid 1 z PCE 3 + Takhzyro 3 Tivicay 2 Spectracef 3 methenamine combination 1 Vecamyl 3 Tybost 2 metronidazole 1 z Vibramycin 3  Verquvo 3 neomycin 1 z Vitekta 2 Antifungals + Vyndaqel 3 nitrofurantoin 1 + z Vyndamax 3 Protease Inhibitors clotrimazole lozenge 1 paromomycin 1  atazanavir 1 fluconazole 1 Pulmonary Arterial Hypertension pentamidine inhal powder 1 z ritonavir tablet 1 flucytosine 1 tinidazole 1  alyq 1 z Aptivus 2 griseofulvin 1 + tobramycin ampule/neb 1 + ambrisentan 1 z + z bosentan 1 Crixivan 2 itraconazole 1 trimethoprim 1  Evotaz 2 ketoconazole 1 vancomycin caps 1 + epoprostenol 1 z Invirase 2 nystatin 1 Firvanq 2 + sildenafil 20 mg tab 1 z Lexiva 2 z oxiconazole 1 z Sivextro 2 + tadalafil (generic Adcirca) 1 P z Norvir capsule, solution 2 z terbinafine 1 + Tobi Podhaler 2 + Adempas 2 z Prezcobix 2 z z Xifaxan 2 + Opsumit 2 voriconazole 1 z Prezista 2 z + Bethkis 3 + Tracleer tab for susp 2 Noxafil 2 + Cayston 3 z Viracept 2 z + Tyvaso 2 P Oxistat lotion 2 z Dificid 3 z Protease Inhibitors Combinations z + Uptravi 2 Kaletra 2 Posaconazole 2 Flagyl/ER 3 z z +P Letairis 3 Sporanox suspension 2 z Impavido 3 Huntington’s Disease z + Orenitram 3 Cresemba 3 +z Kitabis Pak 3 z z +P Revatio 3 + tetrabenazine 1 Ecoza 3 Macrodantin 3 z z z +P sildenafil suspension 3 + Austedo 3 P Ertaczo 3 + Tobi 3 z z z +P Tracleer tab 3  Ingrezza 3 Lamisil Oral 3 Vancocin 3 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

3 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER Men’s Health Antipsychotic Agents Quillivant XR 2 sodium phenylbutyrate 3 Vyvanse 2 z Veltassa Isturisa 3 Impotence aripiprazole 1 chlorpromazine 1 z Adhansia XR 3 z Xuriden 3 z sildenafil citrate 25mg, 50mg, 100mg 1 z clozapine 1 z Adzenys 3  Zokinvy 3 z tadalafil (generic Cialis) 1 fluphenazine 1 z Cotempla XR 3 Miscellaneous Immunologicals z vardenafil 1 haloperidol 1 z Dyanavel XR 3 + Cutaquig 3 z vardenafil ODT 1  loxapine 1 Focalin XR 3 + Cuvitru 3 z Caverject 2 z olanzapine 1 z Jornay PM 3 + Gammagard Liquid 3 z MUSE 2  perphenazine 1 Methylphenidate ER (brand) 3 + Gammaked 3 z Cialis 3 z quetiapine 1 z P Quillichew ER 3 + Gamunex-C 3 z Edex 3 z quetiapine fumarate ER 1 Miscellaneous + Hizentra 3 z  P Levitra 3 z risperidone 1 z Sunosi 3 + HyQvia 3 z   P Staxyn 3 z risperidone m-tab 1 + z Wakix 3 + Xembify 3 z   P Stendra 3 thioridazine 1 z Viagra 3 thiothixene 1 Miscellaneous Multiple Sclerosis Agents P z Male Hormones trifluoperazine 1 Antidiuretic Agents + dalfampridine ER 1 z testosterone cypionate 1 z ziprasidone caps 1 desmopressin solution 1 + dimethyl fumarate 1 testosterone enanthate 1 z Latuda 2 desmopressin tabs 1 + glatiramer acetate 1 z z testosterone gel 1 z Saphris 2 Stimate 2 + glatopa 1 z z testosterone pump 1  Abilify Mycite 3 DDAVP nasal spray 3 + Avonex 2 Androderm patch 2 z Caplyta 3 DDAVP sol, tab 3 + Rebif 2 z Fanapt 3 z Nocdurna 3 + z Gilenya 2 Android 3  z z Fazaclo 3 z Noctiva 3 + Mayzent 2 P Axiron 3  z Invega 3 Other CNS + Plegridy 2 fluoxymesterone 3 z + z Vumerity 2 z Fortesta 3 + Nuplazid 3 acamprosate calcium tablet EC 1  P z olanzapine/fluoxetine 3 + z Zeposia 2 z Jatenzo 3 buprenorphine 1  P z paliperidone 3 buprenorphine-naloxone 1 + z Aubagio 3 z Natesto 3 z P z Rexulti 3 buprenorphine/naloxone film 1 + Bafiertam 3 P Striant 3 z Secuado 3 + Betaseron 3 z disulfiram 1 P P Testim 3 Versacloz 3 + Copaxone 20mg 3 z P naltrexone 1  P Testosterone gel (brand) 3 z Vraylar 3 riluzole 1 + Copaxone 40mg 3 z  P Vogelxo 3 z Zyprexa 3 z Gralise 2 + Extavia 3 z Xyosted 3  zP P z Zyprexa Zydis 3 z Narcan Nasal Spray 2 + Mavenclad 3 Prostate Health Anxiolytics, Sedatives, and Hypnotics z Nuedexta 2 Ponvory 3 z   z alfuzosin 1 alprazolam/ER 1 Savella 2 + Tecfidera 3 z dutasteride 1 buspirone 1 Zubsolv 2 Muscle Relaxants dutasteride/tamsulosin 1 chloral hydrate 1 Bunavail 3 z finasteride 5mg 1 chlordiazepoxide 1 Campral dosepack 3 baclofen 1 silodosin 1 clorazepate 1 z Evzio 3 carisoprodol 1 tamsulosin 1 diazepam 1 Exservan 3 carisoprodol/ASA 1  z z chlorzoxazone 1 Mental Health estazolam 1 P Horizant 3 P z eszopiclone 1 Lucemyra 3 cyclobenzaprine 1 z Antidepressants flurazepam 1 + z Tegsedi 3 P cyclobenzaprine 7.5mg 1 z dantrolene sodium 1 amitriptyline 1 lorazepam 1 P Tiglutik 3 amitriptyline/chlordiazepoxide 1 meprobamate 1 Other Endocrine metaxalone 1 amitriptyline/perphenazine 1 oxazepam 1 cinacalcet 1 methocarbamol 1 amoxapine 1 temazepam 1 danazol 1 orphenadrine 1 bupropion 1 triazolam 1 fludrocortisone 1  orphenadrine/aspirin/caffeine 1 tizanidine 1 bupropion 12HR 1 z zaleplon 1 + miglustat 1 bupropion 24HR 1 z zolpidem 1 + octreotide 1 cyclobenzaprine ER 3 z u citalopram 1 z zolpidem ER 1 + Cerdelga 2  Lorzone 3 z z z clomipramine 1 + Hetlioz 2 + Egrifta 2 P Ozobax 3 desipramine 1 + z Xyrem 2 + z HP Acthar Gel 2  z Osteoporosis desvenlafaxine succinate ER 1 z Ambien 3 + Myalept 2 Pz + Norditropin 2 z alendronate 1 doxepin 1 P Ambien CR 3  Ativan 3 + Sensipar 2 z calcitonin-salmon 1 duloxetine 1 z fortical NS 1 u escitalopram 1 z Belsomra 3 + Somatuline Depot 2 Pz z Synarel 2 z ibandronate tabs 1 u fluoxetine 10mg and 20mg tablet 1  Dayvigo 3  z Edluar 3 + Zavesca 2 z raloxifene 1 fluoxetine capsule 1 P  z z eszopiclone 3 + Genotropin 3 + Forteo 2 u fluvoxamine tablet 1 P z z Intermezzo 3 +P Humatrope 3 + Tymlos 2 imipramine 1 P z Librium 3 + Increlex 3 P Actonel 3 maprotiline 1 z z ramelteon 3  Mycapssa 3 P Atelvia 3 u mirtazapine 1 P + z Natpara 3 z Rozerem 3  P Binosto 3 nefazodone 1 P + Nutropin/AQ 3 z z Silenor 3 P P Boniva 3 nortriptyline 1 P + Omnitrope 3 z Somnote 3 P P Fosamax 3 u paroxetine 1 z + Saizen 3 z Sonata 3 P P Fosamax D 3 phenelzine 1 P z + Sandostatin 3 + Xywav 3 z risedronate 150mg 3 protriptyline 1 z zolpidem ER sublingual tablet 3 +P Serostim 3 z risedronate DR 3 u sertraline 1 Pz + z Somavert 3 P P Zolpimist 3  Pain/Arthritis tranylcypromine 1 Cerebral Stimulants +P Tev-Tropin 3 trazodone 1 z armodafinil 1 +P Zorbtive 3 Analgesics, Opioid - Medications listed under this u venlafaxine 1 atomoxetine 1 Other Miscellaneous category may require additional review for coverage z venlafaxine ER 1 dexmethylphenidate 1 + Keveyis 2 based on recommendations from the Centers for z Viibryd 2 dexmethylphenidate XR 1 + Signifor 2 Disease Control and Prevention (CDC). Desvenlafaxine ER 3 dextroamphetamine tabs 1 + Carbaglu 3 z Cystadane 3 acetaminophen w/codeine 1 Desvenlafaxine Fumarate ER 3 generic Adderall 1 z belladonna & opium supp 1 Drizalma Sprinkle 3 Cystagon 3 P generic Adderall XR 1 + Dojolvi 3 buprenorphine TD patch (generic) 1 Fetzima 3 generic Concerta 1  z butalbital/APAP/codeine 1 fluoxetine 60mg tablet 3 + z Enspryng 3 generic Dexedrine spansules 1 z z butalbital/aspirin/codeine 1 fluvoxamine ER capsule 3 + Evrysdi 3 guanfacine ER 1 z Firdapse 3 z butorphanol NS 1 Forfivo 3 metadate ER 1  z z codeine sulfate 1 Khedezla 3 + Galafold 3 methylphenidate CD 1 z Isturisa 3 z endocet 1 zu Oleptro ER 3  z methylphenidate/SR 1 z Korlym 3  fentanyl lozenge 1 Pexeva 3 z  modafinil 1 + Nityr 3  fentanyl patch 1 Sarafem 3 procentra 1 + Procysbi 3 z hydrocodone/APAP 1 Trintellix 3  z zenzedi 5mg, 10mg 1 + Ravicti 3 hydrocodone/ibuprofen 1 Antimanic Agents Daytrana 2 Revcovi 3 z hydromorphone 1 z  z z lithium carbonate 1 Mydayis 2 + Ruzurgi 3 meperidine 1 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

4 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER methadone 1 butalbital/APAP 50mg-300mg 3 ropinirole ER 3 metaproterenol syr 1  morphine SR 1 Cafergot 3 Rytary 3 terbutaline tab 1 z z  morphine sulfate ER 1 P Cambia 3 tolcapone 3 Arcapta 2 z  morphine tab, soln, supp 1 Ergomar 3 z Xadago 3 z Foradil 2 z z oxycodone 1 P Frova 3 Potassium z Maxair Autohaler 2 z oxycodone/acetaminophen 1 z frovatriptan 3 z z Potassium agents Perforomist 2 oxycodone/aspirin 1 P Imitrex 3 z z potassium bicarb/potassium chloride 1 z ProAir RespiClick 2 oxycodone/ibuprofen 1 P Maxalt 3 z potassium bicarbonate 1 z Serevent Diskus 2  oxymorphone/ER 1 P Maxalt MLT 3 z potassium chloride 1 z z pentazocine/naloxone 1 P Onzetra 3 Ventolin HFA 2 z Buprenorphine 7.5mg TD patch 2 P Relpax 3 Potassium Removing agent Albuterol Sulfate HFA 3 z Butrans 2  Reyvow 3 sod. polystyrene sulfonate 1 Levalbuterol Tartrate HFA 3 z  Kadian (40mg, 70mg, 130mg, P Tosymra 3 Respiratory/Asthma z ProAir HFA 3 150mg, 200mg) 2 tramadol ER capsule 3 z Proventil HFA 3 z z Adrenergic Nucynta 2 +P Zecuity 3 z epinephrine auto-injector 1 z Striverdi Respimat 3  Nucynta ER 2 P Zembrace 3 z Epinephrine (Impax) 2 Xopenex HFA 3  Oxycodone ER 2 P Zomig 3 z Xanthine Derivatives  Oxycontin 2 P Zomig Nasal 3 Epinephrine 0.15mg/0.3ml (Mylan) 2 z Abstral 3 z Zomig ZMT 3 aminophylline 1  P P Adrenaclick 3 z Belbuca 3 Migraine (Miscellaneous) AuviQ 3 theochron 1 z z P theophylline/SR tabs, liquid 1 Demerol 3  Aimovig 2 Epipen/Jr. 3 z P Theo-24 2  Embeda 3  Ajovy 2 Symjepi 3 z Fentanyl buccal tablet 3 z Emgality 2 P Elixophyllin 3   Corticosteroids z Fentora 3 z Nurtec ODT 3   budesonide inh. Seizures fentanyl patch 37.5mcg/hr, 62.5mcg/hr, z Ubrelvy 3   (0.25mg/2ml, 0.5mg/2ml) 1 Barbiturates and 87.5mcg/hr 3 Nonsteroidal Anti-Inflammatory/Combination mephobarbital 1 z Fioricet/codeine 3 z Arnuity Ellipta 2 Products z phenobarbital 1 z Fiorinal/codeine 3 diclofenac potassium 1 Asmanex 2 hydromorphone ER 3 z Flovent HFA/Diskus 2 Hydantoins  diclofenac sodium 1 phenytoin 1  Hysingla ER 3 z diclofenac sodium gel 1% 1 z Pulmicort flexhaler/powder 2 z Lazanda 3 Dilantin 2  etodolac 1 Pulmicort respules (1mg/2ml) 2 Peganone 3 z Roxicet Soln 3 etodolac SA 1 z Qvar 2 z Miscellaneous  Subsys 3 z fenoprofen tablet 1 z Aerobid/M 3 z Trezix 3 P carbamazepine 1 flurbiprofen 1 Alvesco 3 z Tylenol/codeine 3 carbamazepine XR 200mg, 400mg 1 ibuprofen 1 z z Vicodin/ES 3 ArmonAir 3 clobazam 1 indomethacin 1 Leukotrienes clonazepam 1  Xartemis XR 3 ketoprofen 1 z Xtampza ER 3 montelukast 1 divalproex sodium/ER 1  ketorolac inj. 1 felbamate 1 Zohydro ER 3 zafirlukast 1  z ketorolac tab 1 gabapentin 1 Analgesics, Salicylates z zileuton ER 3 meclofenamate 1 z lamotrigine 1 choline mag. trisalicylate 1 mefenamic acid 1 Zyflo 3 Other Agents levetiracetam 1 diflunisal 1 meloxicam 1 oxcarbazepine 1 salsalate 1 nabumetone 1 cromolyn inh. soln. 1 z fluticasone-salmeterol (Prasco) 1 pregabalin 1 z Yosprala 3 naproxen/EC 1 primidone 1 Anti-Rheumatic oxaprozin 1 ipratropium inh. soln. 1 tiagabine 1 ipratropium/albuterol 1 hydroxychloroquine 1 piroxicam 1 topiramate 1 z wixela inhub 1 leflunomide 1 sulindac 1 topiramate ER 1 methotrexate 1 tolmetin 1 Advair HFA 2 valproic acid 1 z z Diclofenac Epolamine patch 3 Anoro Ellipta 2 zonisamide 1  penicillamine 1 P z z diclofenac sodium 3% gel 3 z Atrovent HFA 2 Banzel tablets 2 +P Actemra 2 P z + z Cimzia 2 diclofenac sodium/misoprostol 3 Bevespi Aerosphere 2 z Fycompa 2 P z Breo Ellipta 2 + z Enbrel 2 P diclofenac sodium topical solution 3 Oxtellar XR 2  z z Combivent Respimat 2 + z Humira 2 P Duexis 3 Qudexy XR 2  z Daliresp 2 + z Otezla 2 P Flector 3 Tegretol 2  z + z Esbriet 2 Ridaura 2 P indomethacin 20mg 3  Tegretol XR 100mg 2 z z Licart 3 z Fluticasone-Salmeterol (Teva) 2 Vimpat 2 + Rinvoq 2 P z naproxen CR 375mg tablet 3 z Incruse Ellipta 2 Aptiom 3 + Xeljanz 2 z z Pennsaid 3 + Kalydeco 2 Banzel suspension 3 + Xeljanz XR 2 P  z z Qmiiz ODT 3 + z Ofev 2 z Briviact 3  Cuprimine 3 P  z z Sprix 3 + z Orkambi 2 z Diacomit 3  Depen 3   z Tivorbex 3 + Pulmozyme 2 + Epidiolex 3 + Kevzara 3  z z Vimovo 3 z Spiriva 2 Fintepla 3 P Kineret 3 P  z z Vivlodex 3 z Spiriva Respimat 2 lamotrigine ER/ODT 3 +P Olumiant 3 P z z Zipsor 3 z Stiolto Respimat 2 z Lyrica CR 3 +P Orencia SC 3 P P Otrexup 3 z Zorvolex 3 z Symbicort 2 Potiga 3 P z + Sabril 3 Rasuvo 3 + Symdeko 2 Parkinson’s Disease z z Sympazan 3 + z Simponi 3 Trelegy Ellipta 2 P P benztropine 1 + z Trikafta 2 Trokendi XR 3 Cox-2s  bromocriptine 1 z AirDuo 3 + vigabatrin oral powder 3 z celecoxib 1 carbidopa/levodopa 1 z Xcopri 3 + Bronchitol 3  Migraine (Analgesics, Non-opioid) carbidopa/levodopa SA 1 Budesonide-Formoterol 3 Succinimides butalbital/APAP 50mg-325mg 1 entacapone 1 z ethosuximide 1 P Duaklir Pressair 3 butalbital/APAP/caffeine 1 pramipexole 1 z Dulera 3 Celontin 2 butalbital/aspirin/caffeine 1 z rasagiline 1 Fasenra pen 3 z dihydroergotamine mesylate 1 ropinirole 1  Skin P + Glassia 3 z eletriptan 1 z selegiline 1 z Lonhala Magnair 3 Acne/Rosacea ergotamine/caffeine 1 trihexyphenidyl 1 + z Nucala syringe/auto-inject 3 adapalene/benzoyl peroxide 1 z  isometh/dichloralphen/APAP 1 + Apokyn 2 + Orkambi granules 3 adapalene gel/cream 1 z z  naratriptan 1 + Duopa 2 z Seebri 3 amnesteem 1 z rizatriptan 1 carbidopa 3 Tudorza 3 avita cream 1 z z sumatriptan 1  Gocovri 3 z Utibron 3 azelaic acid gel 1 z tramadol/acetaminopen 1  Inbrija 3 z Yupelri 3 benzoyl peroxide 1 z P tramadol/ER tablet 1  Kynmobi 3 claravis 1 z z Sympathomimetics zolmitriptan 1 + Nourianz 3 clindamycin/benzoyl peroxide z z albuterol sulfate ER 1 Sumavel 2  Ongentys 3 1.2%-2.5%pump 1 z z z albuterol sulfate HFA (generic ProAir HFA, Treximet 2 P Osmolex ER 3 clindamycin/benzoyl peroxide z Proventil HFA) 1 P Amerge 3 pergolide 3 1.2%-2.5% gel 1 z P Axert 3 pramipexole ER 3 albuterol tab, syr 1 clindamycin/benzoyl peroxide 1-5% gel 1 KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

5 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER clindamycin/benzoyl peroxide fluorouracil 5% cr/sol 1  Commit 2 Other Antiulcer 1-5% pump 1 fluorouracil 2% sol 1  Nicotrol Inhaler 2 misoprostol 1 clindamycin phospate 1 imiquimod 5% cream 1  Nicotrol NS 2 propantheline bromide 1 dapsone 5% 1 ivermectin 1  Zyban 3 sucralfate 1 erythromycin/benz peroxide 1 podofilox 1 Pylera 2 z Steroids minocycline 1  prudoxin 1 Helidac 3 prascion RA 1 sodium chloride irrigating soln 1 cortisone acetate 1 lansoprazole/amox/clarith 3 z dexamethasone oral 1 sodium sulfacetamide 1 + Benlysta SC 2 Other GI Products z hydrocortisone oral 1 sod. sulfacetamide/sulfur emulsion + Dupixent 2 balsalazide 1 cleanser 1  Panretin 2 methylprednisolone 4mg, 8mg, budesonide EC 1 sod. sulfacetamide/sulfur lot 1 Phisohex 2 16mg, 32mg 1 cromolyn sodium 1 sotret 1 Picato 2 prednisolone oral 1 enulose 1 tazarotene cream 1 Regranex 2 prednisone oral 1 lactulose 1 tretinoin cr/gel 1 Carac 3 Medrol 2mg 2 mesalamine DR capsule 400mg 1 Absorica 2  Eucresa 3 z mesalamine DR tablet 800mg 1 Atralin 2 Fluoroplex 3 + Emflaza 3 Hemady 3 mesalamine enema 1 Avita gel 2 Fluorouracil 0.5% cream 3 P mesalamine suppository 1 EpiDuo Forte 2 z Rayos 3  Klisyri 3  + sapropterin 1 Mirvaso 2 z  P Qbrexza 3 Stomach/Ulcer sulfasalazine 1 Onexton 2 Regenecare 3 Anorectal sulfasalazine EC 1 Soolantra 2 z Zonalon 3 z  hydrocortisone rectal cr. & supp. 1  Amitiza 2 Tazorac gel 2 Psoralens Cholbam 2 Veltin gel 2 hydrocortisone rectal enema 1  methoxsalen capsule 1 pramoxine/HC acetate 2.5% 1 Linzess 2 Ziana gel 2 8-MOP 2 Pentasa 2 Aczone 3 Analpram-HC 1-1% 2 z Scabicides & Pediculicides  Relistor injection 2 Adapalene lotion 3 Cortifoam 2 z Relistor tablets 2 adapalene solution 3 acticin 1 Proctofoam-HC 2  permethrin 1 z Trulance 2 P adapalene swab 3 Analpram-HC 2.5% cr/lot 3 alosetron 3 Aklief 3 spinosad 1 Anticholinergics/Antispasmodic/GI Motility Lindane 2 Apriso 3 Altreno 3 belladonna/phenobarbital 1 Azulfidine 3 Amzeeq 3 Ulesfia 2 chlordiazepoxide/clindinium 1 Eurax 3 budesonide ER tablet 3 P Doryx 3 dicyclomine 1 z Dipentum 3 doxycycline hyclate DR 3 Sklice 3 P glycopyrrolate 1 + Gattex 3 P Doxycycline IR-DR 3 Topical Anti-Inflammatory Agents hyoscyamine/CR 1 Giazo 3 Fabior 3 alclometasone 1 metoclopramide 1 + Kuvan 3 minocycline HCl ER 3 amcinonide 1 Donnatal tablet 2 mesalamine DR tablet 1.2g 3 Pz P Minolira ER 3 aug. betamethasone diprop 1 z Motegrity 3 Oracea 3 betamethasone dipropionate 1 Antidiarrheal P P diphenoxylate/atropine 1 z Movantik 3 z Seysara 3 betamethasone valerate 1  z P z + Palynziq 3 Solodyn 3 clobetasol emol/emuls 1 nitazoxanide 1 z P  Symproic 3 tretinoin microsphere 3 clobetasol proprionate foam/gel/oint/cr/sol 1 paregoric 1 Uceris 3 Winlevi 3 desonide 1 z Alinia suspension 2 z Xermelo 3 Ximino 3 desoximetasone 1  z P Fulyzaq 2 P Zelnorm 3 Antibiotics (Topical) diflorasone 1 z Alinia tablet 3 Proton Pump Inhibitors clindamycin sol/swabs/gel/lotion 1 fluocinolone acetonide 1 z esomeprazole magnesium 1 fluocinonide 1 Antiemetic/Antivertigo erythromycin sol/swabs/gel 1 z aprepitant 1 z lansoprazole 1 gentamicin cr/oint 1 fluticasone propionate 1  z z granisetron 1 P lansoprazole DR ODT 1 metronidazole cream/lotion/ 0.75% gel 1 halobetasol 1  z Nexium 24HR 1 halobetasol propionate 1 meclizine 1 mupirocin 1 z z omeprazole 1 Metrogel topical 1% 2 z halobetasol propionate foam 1  ondansetron 1  prochlorperazine 1 z pantoprazole 1 Noritate 2 hydrocortisone 2.5% 1 z Prevacid 24HR 1 Bactroban cream 3 hydrocortisone valerate 1 promethazine 1 scopolamine patch 1 z Prilosec-OTC 1 Centany 3 hydrocortisone/iodoquinol 1 z trimethobenzamide 1 rabeprazole 1 P Xepi 3 mometasone cr/oint 1 z Zegerid OTC 1 Antipsoriatics prednicarbate 1 Antivert 50mg 2 z z Nexium DR 2.5mg, 5mg packet 2 acitretin 1 triamcinolone acetonide 1  Anzemet 2 z z Prevacid Solutab 2 calcipotriene 1 Cordran tape 2  Emend 2 z z P Aciphex 3 tacrolimus 1 betamethasone valerate foam 3  Sancuso 2 z Dexilant 3 z P + z Cosentyx 2 Capex Shampoo 3  Varubi 2 z Nexium 3  z P Dritho-Scalp 2 clobetasol propionate P Akynzeo 3 z Nexium DR 10mg, 20mg, 40mg packet 3 Elidel 2 lotion/shampoo/spray 3 z Bonjesta 3 z  P omeprazole/sodium bicarbonate 3 + z Skyrizi 2 Cordran ointment 3 z doxylamine-pyridoxine 3 z Prevacid 3 z z Duobrii 3 z P + Stelara 2 P Granisol 3 z Prilosec 3 z fluocinonide cream (generic Vanos) 3 P + Tremfya 2 z Syndros 3 z Protonix 3 flurandrenolide cream/lotion 3 P P calcipotriene-betamethasone ointment 3 z Zuplenz 3 z Zegerid 3 halcinonide cream 3  P calcitriol ointment 3 Bowel Evacuants Thyroid P Enstilar 3 hydrocortisone butyrate/emoll cream 3 peg 3350/electrolyte 1 + z Siliq 3 Impoyz 3  Antithyroid P P  Trilyte 1 Taclonex 3 Kenalog/aerosol 3 Moviprep 2 methimazole 1 P z  + z Taltz 3  Lexette 3 propylthiouracil 1 P z  Suprep 2 P Wynzora 3  triamcinolone spray 3 Nulytely 3 Thyroid Burn preparation Topical Antipruritics/Anesthetics levothroid 1  Prepopik 3 silver sulfadiazine 1 lidocaine 1 Digestants levothyroxine 1 z Fungicides lidocaine patch 1 Creon 2 levoxyl 1 betamethasone/clotrimazole 1 selenium sulf 2.5% suspension 1 Zenpep 2 liothyronine 1 ciclopirox cream 1 Rectiv 2 Pancreaze 3 thyroid 1 ciclopirox soln 1 Topical Antivirals Pertzye 3 unithroid 1 econazole 1 acyclovir cream 1 Synthroid 2  Sucraid 3 ketoconazole 1 acyclovir ointment 1 Ultresa 3 Thyroid (Armour) 2 nystatin 1 Denavir 3 Viokace 3 Thyrolar 2 nystatin/triamcinolone 1 Tirosint 3 nystop 1 Smoking Cessation Gallstone Solubilizing Agents ursodiol 1 Vaccines Exelderm 2  bupropion 1 + z Ocaliva 3 z Jublia 3  Nicorelief gum 1  Adacel 2 z  Kerydin 3  Nicorelief lozenge 1 H2 Antagonists  Bexsero 2 naftifine 3  Nicotine Gum 1 cimetidine 1  Boostrix 2 Miscellaneous  Nicotine lozenges 1 famotidine 1  Daptacel 2 aluminum chloride 20% 1  Nicotine patches various 1 nizatidine 1  Diphtheria-Tetanus Toxoids-Ped 2 z  doxepin cream 1  Chantix 2 ranitidine (all) 1  Infanrix 2

KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

6 Section I — Therapeutic drug categories (cont’d)

TIER TIER TIER TIER  Influenza 2  NuvaRing 3  balziva 1  new day 1 Paragard 3 bekyree 1 next choice one dose 1  Menactra 2    Today Contraceptive Sponge 3 blisovi 24 fe 1 nikki 1  Menhibrix 2    Menomune-A-C-Y-W-135 2 VCF 3 blisovi fe 1  nora-be 1    norethindrone acetate 1 Menveo A-C-Y-W-135-Dip 2 Fertility Induction Agents  briellyn 1   camila 1 norethindrone-ethin estradiol 1 Pneumovax 23 2 clomiphene 1    camrese 1  norethin-eth estra ferrous fum 1 Prevnar 13 2  progesterone in oil 1  norgestimate-ethinyl estradiol 1   camrese lo 1  Shingrix 2 serophene 1 caziant 1 norgestrel-ethiny estra 1  Bravelle 2   Tetanus Diphtheria Toxoids 2  chateal 1  norlyda 1  Cetrotide 2  norlyroc 1  Tenivac 2   chateal eq 1  Trumenba 2 Follistim AQ 2 cryselle 1  nortrel 1    ocella 1 Zostavax 2  Menopur 3  cyclafem 1   cyred 1 ogestrel 1  Novarel 2   Vitamins cyred eq 1  opcicon one-step 1  Ovidrel 2  option 2 1 calcitriol 1 Repronex 2  dasetta 1  calcitriol inj 1  daysee 1  orsythia 1 Chorionic gonadotropin 3  philith 1 calcium acetate 1   deblitane 1  cholecalciferol 1  Ganirelix 3 delyla 1  pimtrea 1 Gonal F 3  pirmella 1 cyanocobalamin inj. 1 P  desogestrel-ethinyl estradiol 1  ergocalciferol capsule 1 Pregnyl 3 desogestr-eth estrad eth estra 1  portia 1   previfem 1 etidronate 1 Hormones  drospirenone-ethinyl estradiol 1 econtra ez 1  quasense 1  fluoride drops OTC 1 dotti 1  react 1 fluoride tablets OTC 1 z estradiol/noreth ac 1  econtra one-step 1   elinest 1  reclipsen 1 folic acid Rx 1mg tab 1 estradiol 0.01% cream 1  setlakin 1 folic acid tablets OTC 1 z estradiol oral 1  emoquette 1   enpresse 1  sharobel 1 lanthanum carbonate tablet 1 z estradiol patches 1  simliya 1  enskyce 1  leucovorin 1 z estropipate 1 errin 1  simpesse 1 levocarnitine 1 z estrogen/methyltesterone 1  sprintec 1  estarylla 1  multivitamin + fluoride (Rx-only) 1 z jinteli 1  sronyx 1  ethynodiol-ethinyl estradiol 1 syeda 1 + nitisinone 1 medroxyprogesterone 1 fallback solo 1    tarina 24 Fe 1 Pediatric sodium fluoride chewable norethindrone 1  falmina 1 tarina fe 1 tab & drops 1 progesterone, micronized 1 femynor 1    tarina Fe 1-20 eq 1 potassium aminobenzoate 1 yuvafem 1  gianvi 1 tilia fe 1 z gildagia 1  pre-natal vitamins (Rx-only) 1 Alora 2   tri femynor 1 Cenestin 2  gildess 1 tri-estarylla 1 sevelamer 1 gildess 24 fe 1  vit A,D,C + fluoride (Rx-only) 1 z Combipatch 2   tri-legest fe 1  gildess fe 1 tri-linyah 1 vit A,D,C + fluoride and iron (Rx-only) 1 Crinone 2 hailey 24 Fe 1  Galzin 2 Divigel 2   tri-lo-estarylla 1  heather 1 tri-lo-marzia 1 Mephyton 2 Duavee 2 incassia 1  Nascobal 2   tri-lo-mili 1 Endometrin 2  introvale 1 tri-lo-sprintec 1 phytonadione 2 Enjuvia 2 isibloom 1  Prenate Elite 2   tri-mili 1 z Estraderm 2 jasmiel 1 trinessa 1 Renagel 2   z Estring 2  jencycla 1 trinessa lo 1 Renvela 2 jolessa 1  z Evamist 2   tri-previfem 1 Auryxia 3 jolivette 1 tri-sprintec 1 paricalcitol 3 Menest 2   z  juleber 1 trivora 1 Poly-Vi-Flor +> Iron 3 Minivelle 2 junel 1  Premarin 2   tri-vylibra 1 z Rayaldee 3 junel fe 1 tri-vylibra lo 1 Tri-Vi-Flor 3 Premarin vag cream 2    kaitlib fe 1 tulana 1 Velphoro 3 Premphase 2 kalliga 1    tydemy 1 Weight Loss Prempro 2  kariva 1 velivet 1 z Climara Pro 3 kelnor 1-35 1  benzphetamine 1   vestura 1  z Estrasorb packet 3 kelnor 1-50 1 diethylpropion 1   vienva 1  z kimidess 1 viorele 1 phendimetrazine 1 Estrogel 3    z Femring 3  kurvelo 1 vyfemla 1 phentermine 1 larin 1   z Imvexxy 3   vylibra 1  Belviq 3 larin fe 1 wera 1 z z Intrarosa 3    Belviq XR 3 larissia 1 wymzya fe 1 z z    Contrave 3 Menostar 3 layolis fe 1 zarah 1 z z    Imcivree 3  Oriahnn 3 leena 1 zenchent 1 z    Lomaira 3 z Orilissa 3 lessina 1 zenchent fe 1 z     Qsymia 3 Ortho-Est 3 levonest 1 zeosa 1 z Saxenda 3    Osphena 3  levonorgestrel 1  zovia 1  Suprenza ODT 3 z Prefest 3 levonorgestrel-eth estradiol 1 zumandimine 1 Xenical 3    Miscellaneous  levonorg-eth estrad eth estrad 1  Lo Loestrin Fe 2 Women’s Health paroxetine 7.5mg 1  levora 1  Natazia 2 z lillow 1 Balcoltra 3 Please refer to your plan documents to confirm your  Addyi 3   z Vyleesi 3  lomedia 24 fe 1  drospirenone-eth estra-levomef 3 cost share for contraceptives. Cost share may vary  Ella 3 Oral Contraceptives  loryna 1  by plan. low-ogestrel 1  fayosim 3  afirmelle 1  rajani 3 Contraceptives - Other altavera 1  lo-zumandimine 1  eluryng vaginal ring 1  lutera 1  rivelsa 3   alyacen 1  Slynd 3  etonogestrel/ethinyl estradiol vaginal ring 1 amethia 1  lyza 1  xulane 1  marlissa 1  Taytulla 3   amethia lo 1   Mirena 2  melodetta 24 fe 1 Oxytocic Agents  amethyst 1 methylergonovine maleate 1  Skyla 2  mibelas 24 fe 1  apri 1 microgestin 1 Methergine 3  Caya Contoured Diaphragm 3 aranelle 1  Conceptrol 3   microgestin fe 1 Vaginal Preparations   ashlyna 1  Depo-SubQ Provera 3  mili 1 miconazole vag supp 1  aubra 1 mono-linyah 1 nystatin vag tab 1  FC2 Female Condom 3 aubra eq 1  Femcap 3   mononessa 1 terconazole 1   aurovela 1 my choice 1 vandazole vag 1  gynol II 3 aurovela 24 Fe 1  Kyleena 3   my way 1 Cleocin Vag/Ovules 3   aviane 1 myzilra 1 Clindesse 3 + Liletta 3 ayuna 1  + Nexplanon 3   necon 1 Gynazole-1   azurette 1

KEY: P = A step edit applies to this drug. u = Included in Tablet-Splitting Program z = Specific Quantity Limits Apply. + = Access restricted to specialty pharmacy.  = Prior Authorization Required.  = ACA Preventive Drug

7 Section II — Index

DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE A amlodipine/atorvastatin 2 Baqsimi 2 calcipotriene-betamethasone clemastine 1 DDAVP nasal spray 4 abacavir-lamivudine 3 amlodipine/benazepril 2 Baraclude solution 3 ointment 6 Cleocin 3 DDAVP sol, tab 4 abacavir/lamivudine/zidovudine 3 amlodipine/valsartan 2 Basaglar 1 calcitonin-salmon 4 Cleocin Vag/Ovules 7 deblitane 7 Abilify Mycite 4 amlodipine/valsartan/HCTZ 2 Baxdela 3 calcitriol 7 Climara Pro 7 deferasirox 1 abiraterone acetate 1 amnesteem 5 Beconase AQ 1 calcitriol inj 7 clindamycin 3 deferiprone 1 Absorica 6 amoxapine 4 bekyree 7 calcitriol ointment 6 clindamycin/benzoyl peroxide delyla 7 Abstral 5 amoxicillin 3 Belbuca 5 calcium acetate 7 1.2%-2.5% gel 5 Demerol 5 acamprosate calcium tablet EC 4 amoxicillin-clavulanate ER 3 belladonna & opium supp 4 Calquence 1 clindamycin/benzoyl peroxide Denavir 6 1.2%-2.5%pump 5 acarbose 1 ampicillin 3 belladonna/phenobarbital 6 Cambia 5 Depen 5 clindamycin/benzoyl peroxide Accu-Chek 2 Amturnide 3 Belsomra 4 camila 7 Depo-SubQ Provera 7 Amzeeq 6 Belviq 7 Campral dosepack 4 1-5% gel 6 Descovy 3 acebutolol 2 clindamycin/benzoyl peroxide acetaminophen w/codeine 4 anagrelide 1 Belviq XR 7 camrese 7 desipramine 4 Analpram-HC 1-1% 6 benazepril 2 camrese lo 7 1-5% pump 6 desloratadine 1 acetazolamide 3 clindamycin phospate 6 acetazolamide ER 3 Analpram-HC 2.5% cr/lot 6 benazepril/HCTZ 2 candesartan/HCTZ 3 desmopressin solution 4 anastrozole 1 Benlysta SC 6 capecitabine 1 clindamycin sol/swabs/gel/lotion 6 desmopressin tabs 4 acetic acid HC otic 2 Clindesse 7 acetic acid otic 2 Androderm patch 4 benzonatate 1 Capex Shampoo 6 desogestr-eth estrad eth estra 7 Android 4 benzoyl peroxide 5 Caplyta 4 clobazam 5 desogestrel-ethinyl estradiol 7 acetic acid/aluminum acetate 2 clobetasol emol/emuls 6 acetylcysteine inh soln. 1 Anoro Ellipta 5 benzphetamine 7 Caprelsa 1 desonide 6 Antivert 50mg 6 benztropine 5 captopril 2 clobetasol propionate lotion/ desoximetasone 6 Aciphex 6 shampoo/spray 6 Anzemet 6 Bepreve 2 captopril/HCTZ 3 Desvenlafaxine ER 4 acitretin 6 clobetasol proprionate foam/gel/oint/ Berinert 3 Carac 6 Desvenlafaxine Fumarate ER 4 Actemra 5 Apidra 1 cr/sol 6 Besivance 2 Carbaglu 4 desvenlafaxine succinate ER 4 acticin 6 Apokyn 5 clomiphene 7 betamethasone dipropionate 6 carbamazepine 5 Detrol 1 Actimmune 1 aprepitant 6 clomipramine 4 Actonel 4 apri 7 betamethasone valerate 6 carbamazepine XR Detrol LA 1 betamethasone valerate foam 6 200mg, 400mg 5 clonazepam 5 Acular PF 2 Apriso 6 clonidine, oral, patch 2 dexameth/neomycin/poly B 2 betamethasone/clotrimazole 6 carbidopa 5 acyclovir cream 6 Aptiom 5 clopidogrel 1 dexamethasone oral 6 Betaseron 4 carbidopa/levodopa 5 acyclovir ointment 6 Aptivus 3 clorazepate 4 dexchlorpheniramine 1 betaxolol 2 carbidopa/levodopa SA 5 acyclovir oral 3 aranelle 7 clotrimazole lozenge 3 Dexilant 6 betaxolol HCl 2 carbinoxamine 1 Aczone 6 Aranesp 1 clozapine 4 dexmethylphenidate 4 Bethkis 3 Cardec/DM 1 Adacel 6 Arcalyst 1 Coartem 3 dexmethylphenidate XR 4 adapalene gel/cream 5 Arcapta 5 Betoptic-S 2 Cardura XL 2 dextroamphetamine tabs 4 Bevespi Aerosphere 5 codeine sulfate 4 Adapalene lotion 6 aripiprazole 4 carisoprodol 4 Diacomit 5 Bevyxxa 1 colchicine/probenecid 2 adapalene solution 6 armodafinil 4 carisoprodol/ASA 4 diazepam 4 bexarotene 1 colchicine (generic Colcrys) 2 adapalene swab 6 ArmonAir 5 Carospir 3 diclofenac 2 Bexsero 6 colesevelam 2 Addyi 7 Arnuity Ellipta 5 carteolol 2 Diclofenac Epolamine patch 5 Biaxin XL 3 Colestid 2 Adempas 3 Ascensia Breeze 2 cartia XT 2 diclofenac potassium 5 bicalutamide 1 colestipol 2 Adhansia XR 4 ashlyna 7 carvedilol 2 diclofenac sodium 5 Biktarvy 3 Combigan 2 Adlyxin 1 Asmanex 5 carvedilol ER 2 diclofenac sodium 3% gel 5 bimatoprost 0.03% 2 Combipatch 7 Admelog 1 aspirin 325mg OTC 1 Caverject 4 diclofenac sodium gel 1% 5 Binosto 4 Combivent Respimat 5 Adrenaclick 5 aspirin 81mg OTC 1 Caya Contoured Diaphragm 7 diclofenac sodium bisoprolol 2 Cometriq 1 Advair HFA 5 aspirin/dipyridamole 1 Cayston 3 topical solution 5 bisoprolol/HCTZ 3 Commit 6 Advicor 2 Astagraf XL 3 caziant 7 diclofenac sodium/misoprostol 5 blisovi 24 fe 7 Complera 3 Adzenys 4 atazanavir 3 CeeNu 1 dicloxacillin 3 blisovi fe 7 Conceptrol 7 Aerobid/M 5 Atelvia 4 cefaclor 3 dicyclomine 6 Boniva 4 Conjupri 2 Afinitor 1 atenolol 2 cefadroxil 3 didanosine 3 Bonjesta 6 Consensi 3 afirmelle 7 atenolol/chlorthalidone 2 cefdinir 3 diethylpropion 6 Boostrix 6 Contour 2 Afrezza 2 Ativan 4 cefixime 3 Dificid 3 bosentan 3 Contrave 7 Aimovig 5 atomoxetine 4 cefpodoxime 3 diflorasone 6 Bosulif 1 Copaxone 20mg 4 AirDuo 5 atorvastatin calcium 2 cefprozil 3 diflunisal 5 Braftovi 1 Copaxone 40mg 4 Ajovy 5 atovaquone 3 Ceftin 3 digoxin 2 Bravelle 7 Copiktra 1 Aklief 6 atovaquone/proguanil HCl 3 cefuroxime 3 dihydroergotamine mesylate 5 Breo Ellipta 5 Cordran ointment 6 Akynzeo 6 Atralin 6 celecoxib 4 Dilantin 5 briellyn 7 Cordran tape 6 albuterol sulfate ER 5 Atripla 3 Cellcept 3 Dilatrate SR 3 Brilinta 1 Corlanor 3 Albuterol Sulfate HFA 5 atropine sulfate ophth 2 Celontin 5 diltia XT 2 brimonidine 2 Cortifoam 6 albuterol sulfate HFA (generic ProAir Atrovent HFA 5 Cenestin 7 diltiazem 2 brinzolamide 2 cortisone acetate 6 HFA, Proventil HFA) 5 Atrovent Nasal Spray 1 Centany 6 diltiazem CD/SR/ER/XR 2 Briviact 5 Cosentyx 6 albuterol tab, syr 5 Aubagio 4 cephalexin 3 dimethyl fumarate 4 bromfenac 2 Cotellic 1 alclometasone 6 aubra 7 Cequa 2 Dipentum 6 bromocriptine 5 Cotempla XR 4 Alecensa 1 aubra eq 7 Cerdelga 4 diphenhydramine 1 brompheniramine/phenylephrine 1 Coumadin 1 alendronate 4 aug. betamethasone diprop 6 cetirizine 1 diphenoxylate/atropine 6 brompheniramine/ Creon 6 alfuzosin 4 Cetrotide 7 Diphtheria-Tetanus Toxoids-Ped 6 aurovela 7 pseudoephedrine 1 Cresemba 3 Alinia suspension 6 Chantix 6 dipyridamole 1 aurovela 24 Fe 7 Bronchitol 5 Crestor 2 Alinia tablet 6 chateal 7 disopyramide 2 Auryxia 7 Brukinsa 1 Crinone 7 aliskiren 2 chateal eq 7 disulfiram 4 Austedo 3 budesonide EC 6 Crixivan 3 Alkeran 1 chloral hydrate 4 Ditropan XL 1 AuviQ 5 budesonide ER tablet 6 cromolyn inh. soln. 5 allopurinol 2 chlordiazepoxide 4 divalproex sodium/ER 5 Avandamet 2 Budesonide-Formoterol 5 cromolyn ophth 2 Alomide 2 chlordiazepoxide/clindinium 6 Divigel 7 Avandaryl 2 budesonide inh. (0.25mg/2ml, cromolyn sodium 6 chloroquine phosphate 3 Alora 7 Avandia 2 0.5mg/2ml) 5 cryselle 7 dofetilide 2 chlorothiazide 3 alosetron 6 aviane 7 budesonide nasal spray 1 Cuprimine 5 Dojolvi 4 chlorpromazine 4 Alphagan P 0.1% 2 avita cream 5 bumetanide 3 Cutaquig 4 Domeboro 2 chlorpropamide 1 alprazolam/ER 4 Avita gel 6 Bunavail 4 Cuvitru 4 donepezil 1 chlorthalidone 3 Alprolix 1 Avonex 4 buprenorphine 4 cyanocobalamin inj. 7 Donnatal tablet 6 chlorzoxazone 4 Alrex 2 Axert 5 Buprenorphine 7.5mg TD patch 5 cyclafem 7 Doptelet 1 altavera 7 Axiron 4 buprenorphine TD patch (generic) 4 Cholbam 6 cyclobenzaprine 4 Doryx 6 Altoprev 2 ayuna 7 buprenorphine-naloxone 4 cholecalciferol 7 cyclobenzaprine 7.5mg 4 dorzolamide 2% eye drops 2 Altreno 6 Ayvakit 1 buprenorphine/naloxone film 4 cholestyramine 2 cyclobenzaprine ER 4 dorzolamide/timolol eye drops 2 aluminum chloride 20% 6 Azasite 2 bupropion 4 choline mag. trisalicylate 5 cyclophosphamide 1 dotti 7 Alunbrig 1 azathioprine 3 bupropion 6 Chorionic gonadotropin 7 cyclosporine 3 doxazosin 2 Alvesco 5 azelaic acid gel 5 bupropion 12HR 4 Cialis 4 cyproheptadine 1 doxepin 4 alyacen 7 azelastine nasal spray 1 bupropion 24HR 4 ciclopirox cream 6 cyred 7 doxepin cream 6 alyq 3 azelastine ophth 2 buspirone 4 ciclopirox soln 6 cyred eq 7 doxycycline 3 amantadine 3 azithromycin suspension 3 butalbital/APAP 50mg-300mg 5 cilostazol 1 Cystadane 4 doxycycline hyclate 50mg, 75mg, Ambien 4 azithromycin tablets 3 butalbital/APAP 50mg-325mg 5 Ciloxan 2 Cystadrops 2 150mg tab 3 Ambien CR 4 Azopt 2 butalbital/APAP/caffeine 5 Cimduo 3 Cystagon 4 doxycycline hyclate DR 6 ambrisentan 3 Azulfidine 6 butalbital/APAP/codeine 4 cimetidine 6 Cystaran 2 Doxycycline IR-DR 6 amcinonide 6 azurette 7 butalbital/aspirin/caffeine 5 Cimzia 5 doxylamine-pyridoxine 6 Amerge 5 cinacalcet 4 D Dritho-Scalp 6 B butalbital/aspirin/codeine 4 amethia 7 butorphanol NS 4 Cinryze 3 dalfampridine ER 4 Drizalma Sprinkle 4 amethia lo 7 bacitracin ophth 2 Butrans 5 Cipro HC 2 Daliresp 5 drospirenone-eth estra-levomef 7 amethyst 7 bacitracin/polymyxin 2 Bydureon 1 ciprofloxacin 3 danazol 4 drospirenone-ethinyl estradiol 7 amiloride 3 baclofen 4 Byetta 1 ciprofloxacin/dexamethasone 2 dantrolene sodium 4 droxidopa 2 amiloride/HCTZ 3 Bactroban cream 6 Bystolic 2 ciprofloxacin ophth 2 dapsone 5% 6 Duaklir Pressair 5 aminophylline 5 Bafiertam 4 Byvalson 3 ciprofloxacin otic 2 dapsone tablets 3 Duavee 7 amiodarone 2 Balcoltra 7 citalopram 4 Daptacel 6 Duetact 2 Amitiza 6 balsalazide 6 C claravis 5 dasetta 7 Duexis 5 amitriptyline 4 Balversa 1 Cablivi 1 Clarinex-D 1 Daurismo 1 Dulera 5 amitriptyline/chlordiazepoxide 4 balziva 7 Cabometyx 1 Clarispray 1 daysee 7 duloxetine 4 amitriptyline/perphenazine 4 Banzel suspension 5 Cafergot 5 clarithromycin susp 3 Daytrana 4 Duobrii 6 amlodipine 2 Banzel tablets 5 calcipotriene 6 clarithromycin tabs 3 Dayvigo 4 Duopa 5

8 Section II — Index (cont’d)

DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE Dupixent 6 estarylla 7 Fluoroplex 6 Gocovri 5 Intelence 3 L Durlaza 1 estazolam 4 Fluorouracil 0.5% cream 6 Gonal F 7 Intermezzo 4 labetalol 2 dutasteride 4 Estraderm 7 fluorouracil 2% sol 6 Gonitro 3 Intrarosa 7 lactulose 6 dutasteride/tamsulosin 4 estradiol 0.01% cream 6 fluorouracil 5% cr/sol 6 Gralise 4 Intron A 1 Lamisil Oral 3 Dutrebis 3 estradiol oral 6 fluoxetine 10mg and 20mg tablet 4 granisetron 6 introvale 7 lamivudine tabs 3 Duzallo 2 estradiol patches 6 fluoxetine 60mg tablet 4 Granisol 6 Invega 4 lamivudine/zidovudine 3 Dyanavel XR 4 estradiol/noreth ac 6 fluoxetine capsule 4 Granix 1 Invirase 3 lamotrigine 5 Dymista 1 Estrasorb packet 7 fluoxymesterone 4 Grastek 1 Invokamet 2 lamotrigine ER/ODT 5 Dynacirc/CR 2 Estring 7 fluphenazine 4 griseofulvin 3 Invokamet XR 2 Lanoxin 2 Estrogel 7 Guaifenesin DM 1 E flurandrenolide cream/lotion 6 Invokana 2 lansoprazole 6 estrogen/methyltesterone 6 flurazepam 4 guaifenesin/codeine 1 ipratropium inh. soln. 5 lansoprazole DR ODT 6 econazole 6 estropipate 6 flurbiprofen 5 guanfacine 2 ipratropium nasal spray 1 lansoprazole/amox/clarith 6 econtra ez 7 eszopiclone 4 flurbiprofen ophth 2 guanfacine ER 4 ipratropium/albuterol 5 lanthanum carbonate tablet 7 econtra one-step 7 ethambutol 3 flutamide 1 Gynazole-1 7 irbesartan 2 Lantus 1 Ecoza 3 ethosuximide 5 fluticasone nasal spray 1 gynol II 7 irbesartan/HCTZ 3 lapatinib 1 Edarbi 2 ethynodiol-ethinyl estradiol 7 fluticasone propionate 6 Iressa 1 larin 7 Edarbyclor 3 H etidronate 7 fluticasone-salmeterol (Prasco) 5 Isentress 3 larin fe 7 Edex 4 Haegarda 3 etodolac 5 Fluticasone-Salmeterol (Teva) 5 isibloom 7 larissia 7 Edluar 4 hailey 24 Fe 7 etodolac SA 5 fluvastatin 2 isometh/dichloralphen/APAP 4 latanoprost 2 Edurant 3 halcinonide cream 6 etonogestrel/ethinyl estradiol fluvoxamine ER capsule 4 isoniazid 3 Latuda 4 efavirenz 3 vaginal ring 1 halobetasol 6 fluvoxamine tablet 4 isosorbide dinitrate 3 layolis fe 7 efavirenz/emtricit/tenofovr df 3 etoposide 1 halobetasol propionate 6 FML Forte 2 isosorbide mononitrate 3 Lazanda 5 efavirenz/lamivu/tenofovr diop 3 Eucresa 6 halobetasol propionate foam 6 FML S.O.P. 2 Ledipasvir/Sofosbuvir 3 Egrifta 4 Eurax 6 haloperidol 4 isosorbide mononitrate SA 3 Focalin XR 4 leena 7 8-MOP 6 Evamist 7 Harvoni 3 isoxsuprine 3 folic acid Rx 1mg tab 7 leflunomide 5 eletriptan 4 everolimus (generic Afinitor) 1 heather 7 isradipine 2 folic acid tablets OTC 7 Lenvima 1 Elidel 6 Evotaz 3 Helidac 6 Istalol 2 Follistim AQ 6 Lescol 2 elinest 7 Evrysdi 4 Hemady 6 Isturisa 4 fondaparinux sodium 1 Lescol XL 2 Eliquis 1 Evzio 4 Hemangeol 2 itraconazole 3 Foradil 5 lessina 7 Elixophyllin 5 Exelderm 6 Hemlibra 1 ivermectin 6 Forfivo 4 Letairis 3 Ella 7 exemestane 1 heparin 1 Izba 2 Fortamet 2 letrozole 1 Eloctate 1 Exjade 1 Hepsera 3 Forteo 4 J leucovorin 7 eluryng vaginal ring 7 Exservan 4 Hetlioz 4 Fortesta 4 Jadenu 1 Leukeran 1 Embeda 5 Extavia 4 Hexalen 1 fortical NS 4 Jakafi 1 Leukine 1 Emcyt 1 Ezallor 2 Hizentra 4 Fosamax 4 jantoven 1 leuprolide 1 Emend 6 ezetimibe 2 homatropine 2 Fosamax D 4 Janumet 2 Levalbuterol Tartrate HFA 5 Emflaza 6 ezetimibe-simvastatin 2 Horizant 4 fosinopril 2 Janumet XR 2 Levemir 1 Emgality 5 HP Acthar Gel 4 F fosinopril/HCTZ 3 Januvia 2 levetiracetam 5 emoquette 7 Humalog insulin 1 Fotivda 1 Jardiance 2 Levitra 4 emtricitabine 3 Fabior 6 Humatrope 4 Fragmin 1 jasmiel 7 levobunolol 2 emtricitabine/tenofovir disop 3 Factive 3 Humira 5 Freestyle 2 Jatenzo 4 levocarnitine 7 Emtriva solution 3 fallback solo 7 Humulin (all types) 1 Frova 5 jencycla 7 levocetirizine 1 Enablex 1 falmina 7 Hycamtin capsule 1 famciclovir 3 frovatriptan 5 Jentadueto 2 levofloxacin 3 enalapril 2 Hycodan 1 famciclovir ophth 2 Fulphila 1 Jentadueto XR 2 levonest 7 enalapril/HCTZ 3 hydralazine 3 famotidine 6 Fulyzaq 6 levonorg-eth estrad eth estrad 7 Enbrel 5 hydrochlorothiazide 2 jinteli 6 Fanapt 4 furosemide 3 levonorgestrel 7 Endari 1 hydrocodone/APAP 4 Jivi 1 Fareston 1 Fuzeon 3 hydrocodone/chlorpheniramine 1 jolessa 7 levonorgestrel-eth estradiol 7 endocet 4 levora 7 Farxiga 2 Fycompa 5 hydrocodone/homatropine 1 jolivette 7 Endometrin 7 levothroid 6 Farydak 1 hydrocodone/ibuprofen 4 Enjuvia 7 G Jornay PM 4 levothyroxine 6 Fasenra pen 5 enoxaparin 1 gabapentin 5 hydrocortisone 2.5% 6 Jublia 6 levoxyl 6 fayosim 7 enpresse 7 Galafold 4 hydrocortisone butyrate/emoll cream 6 juleber 7 Lexette 6 Fazaclo 4 enskyce 7 galantamine 1 hydrocortisone oral 6 Juluca 3 Lexiva 3 FC2 Female Condom 7 Enspryng 4 galantamine ER 1 hydrocortisone rectal cr. & supp. 6 junel 7 Librium 4 febuxostat 2 hydrocortisone rectal enema 6 Enstilar 6 Galzin 7 junel fe 7 Licart 5 felbamate 5 hydrocortisone valerate 6 entacapone 5 Gammagard Liquid 4 Juvisync 2 lidocaine 6 felodipine ER 2 hydrocortisone/iodoquinol 6 entecavir tablets 3 Gammaked 4 Juxtapid 2 lidocaine patch 6 Femcap 7 hydromorphone 4 Entresto 3 Gamunex-C 4 Jynarque 1 Liletta 7 Femring 7 hydromorphone ER 5 lillow 7 enulose 6 ganciclovir 3 femynor 7 hydroxychloroquine 5 K Lindane 6 Envarsus XR 3 Ganirelix 7 fenofibrate (generic) 2 hydroxyurea 1 K-Phos 1 linezolid 3 Epaned 2 Gavreto 1 Fenofibrate 160mg tab (brand) 2 hydroxyzine HCl 1 Kadian (40mg, 70mg, 130mg, Linzess 6 Epanova 2 gatifloxacin 2 Fenofibrate 50mg, 150mg cap hydroxyzine pamoate 1 150mg, 200mg) 5 liothyronine 6 Epclusa 3 Gattex 6 (brand) 2 hyoscyamine/CR 6 kaitlib fe 7 Lipitor 2 Epidiolex 5 Gelnique 1 fenofibric acid, capsule DR 2 HyQvia 4 Kaletra 3 Lipofen 2 EpiDuo Forte 6 gemfibrozil 2 fenofibric acid, tab 2 Hysingla ER 5 kalliga 7 lisinopril 2 Epinephrine (Impax) 5 Gemtesa 1 lisinopril/HCTZ 3 fenoprofen tablet 5 Kalydeco 5 Epinephrine generic Adderall 4 I lithium carbonate 4 Fentanyl buccal tablet 5 kariva 7 0.15mg/0.3ml (Mylan) 5 generic Adderall XR 4 Livalo 2 fentanyl lozenge 4 ibandronate tabs 4 Katerzia 2 epinephrine auto-injector 5 fentanyl patch 4 generic Concerta 4 Ibrance 1 Lo Loestrin Fe 7 Kazano 2 Lomaira 7 Epipen/Jr. 5 fentanyl patch 37.5mcg/hr, generic Dexedrine spansules 4 ibuprofen 5 kelnor 1-35 7 lomedia 24 fe 7 Epivir solution 3 62.5mcg/hr, and 87.5mcg/hr 5 gengraf 3 icatibant 3 kelnor 1-50 7 Lonhala Magnair 5 Epivir-HBV solution 3 Genotropin 4 Iclusig 1 Fentora 5 Kenalog/aerosol 6 Lonsurf 1 eplerenone 3 Ferriprox 1 gentamicin cr/oint 6 Idhifa 1 Kerydin 6 loratadine 1 Epogen 1 Fetzima 4 gentamicin ophth 2 Ilevro 2 Kesimpta 1 loratadine-D 1 epoprostenol 3 Fiasp 1 Genvoya 3 imatinib 1 Ketek 3 lorazepam 4 eprosartan 600mg 2 finasteride 5mg 4 gianvi 7 Imbruvica 1 ketoconazole 3 Lorbrena 1 ergocalciferol capsule 7 Fintepla 5 Giazo 6 Imcivree 7 ketoconazole 6 loryna 7 ergoloid mesylates 1 Fioricet/codeine 5 gildagia 7 imipramine 4 Lorzone 4 ketoprofen 5 Ergomar 5 Fiorinal/codeine 5 gildess 7 imiquimod 5% cream 6 losartan 2 ergotamine/caffeine 4 Firazyr 3 gildess 24 fe 7 Imitrex 5 ketorolac inj. 5 losartan/HCTZ 3 Erivedge 1 Firdapse 4 gildess fe 7 Impavido 3 ketorolac tab 5 Lotemax gel 2 Erleada 1 Firvanq 3 Gilenya 4 Impoyz 6 ketotifen opthalmic solution 2 Lotemax ointment 2 erlotinib 1 Flagyl/ER 3 Gilotrif 1 Imvexxy 7 Keveyis 4 Lotemax SM 2 errin 7 Flarex 2 Glassia 5 Inbrija 5 Kevzara 5 loteprednol Ertaczo 3 flecainide 2 glatiramer acetate 4 incassia 7 Khedezla 4 loteprednol etabonate susp 2 ery-tab 250mg, 333mg 3 Flector 5 glatopa 4 Increlex 4 kimidess 7 lovastatin 2 erythromycin base 3 Flonase Allergy Relief 1 Gleevec 1 Incruse Ellipta 5 Kineret 5 low-ogestrel 7 erythromycin DR 3 Flonase Sensimist 1 glimepiride 1 indapamide 2 Kisqali 1 loxapine 4 lo-zumandimine 7 erythromycin estolate 3 Flovent HFA/Diskus 5 glipizide 1 indomethacin 5 Kisqali Femara Co-Pack 1 Lucemyra 4 erythromycin ethylsuccinate 3 glipizide ER 1 Kitabis Pak 3 fluconazole 3 indomethacin 20mg 5 Lumigan 0.01% 2 erythromycin ophth 2 glipizide/metformin 1 Klisyri 6 flucytosine 3 Infanrix 6 Lupkynis 3 Kombiglyze XR 2 erythromycin sol/swabs/gel 6 fludrocortisone 4 Gloperba 2 Influenza 7 lutera 7 erythromycin stearate 3 flunisolide nasal spray 1 GlucaGen 2 Ingrezza 3 Korlym 4 Luzu 3 erythromycin/benz peroxide 6 fluocinolone acetonide 6 Glucagon 2 Inlyta 1 Koselugo 1 Lymepak 3 erythromycin/sulfisoxazole 3 fluocinonide 6 Glumetza 2 Innohep 1 kurvelo 7 Lynparza 1 erythromycin suspension 3 fluocinonide cream (generic Vanos) 6 glyburide 1 Innopran XL 2 Kuvan 6 Lyrica CR 5 Esbriet 5 fluoride drops OTC 7 glyburide micronized 2 Inqovi 1 Kyleena 7 Lysodren 1 escitalopram 4 fluoride tablets OTC 7 glycopyrrolate 6 Inrebic 1 Kynamro 2 Lyumjev 1 esomeprazole magnesium 6 fluorometholone ophth 2 Glyxambi 2 Insulin Lispro 1 Kynmobi 5 lyza 7

9 Section II — Index (cont’d)

DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE M minocycline HCl ER 6 Nikita 2 Oracea 6 pindolol 2 pyrazinamide 3 Macrodantin 3 Minolira ER 6 nikki 7 Oracit 1 pioglitazone/metformin 2 pyrimethamine 3 maprotiline 4 minoxidil oral 3 nilutamide 1 Oralair 1 Piqray 1 Q Mircera 1 nimodipine 2 Oravig 3 pirmella 7 marlissa 7 Qbrelis 2 Matulane 1 Mirena 7 Ninlaro 1 Orencia SC 5 piroxicam 5 mirtazapine 4 nisoldipine 2 Orenitram 3 Plegridy 4 Qbrexza 6 Mavenclad 4 Qinlock 1 Mavyret 3 Mirvaso 6 nitazoxanide 6 Orgovyx 1 Pneumovax 23 7 misoprostol 6 nitisinone 7 Oriahnn 7 podofilox 6 Qmiiz ODT 5 Maxair Autohaler 5 Qnasl 1 Maxalt 5 Mitigare 2 NitroDur patches 3 Orilissa 7 Poly-Vi-Flor +> Iron 7 modafinil 4 nitrofurantoin 3 Orkambi 5 polymyxin B/TMP 2 Qsymia 7 Maxalt MLT 5 Qtern 2 Maxidex 2 moderiba 3 nitrofurantoin 3 Orkambi granules 5 Pomalyst 1 moexipril 2 nitroglycerin pumpspray 3 Orladeyo 3 Ponvory 4 quasense 7 Maxitrol ophth 2 Qudexy XR 5 mometasone cr/oint 6 nitroglycerin SR 3 orphenadrine 4 portia 7 Mayzent 4 quetiapine 4 mometasone nasal spray 1 nitroglycerin transdermal patch 3 orphenadrine/aspirin/caffeine 4 Posaconazole 3 meclizine 6 quetiapine fumarate ER 4 mono-linyah 7 Nitrostat SL tabs 3 orsythia 7 potassium aminobenzoate 7 meclofenamate 5 Quillichew ER 4 mononessa 7 Nityr 4 Ortho-Est 7 potassium bicarb/potassium Medrol 2mg 6 Quillivant XR 4 medroxyprogesterone 7 montelukast 5 Nivestym 1 oseltamivir 3 chloride 5 morphine SR 5 nizatidine 6 Oseni 2 potassium bicarbonate 5 quinapril 2 mefenamic acid 5 quinapril/HCTZ 3 mefloquine 3 morphine sulfate ER 5 Nocdurna 4 Osmolex ER 5 potassium chloride 5 morphine tab, soln, supp 5 Noctiva 4 Osphena 7 potassium citrate 1 quinidine gluconate 2 megestrol 1 quinidine sulfate SR 2 Mekinist 1 Motegrity 6 nora-be 7 Otezla 5 Potiga 5 Movantik 6 Norditropin 4 Otrexup 5 Pradaxa 1 quinine sulfate 3 Mektovi 1 Qvar 5 melodetta 24 fe 7 Moviprep 6 norethin-eth estra ferrous fum 7 Ovidrel 7 Praluent 2 meloxicam 5 Moxeza 2 norethindrone 7 oxaprozin 5 pramipexole 5 R memantine 1 moxifloxacin 0.5% (generic Vigamox) 2 norethindrone acetate 7 oxazepam 4 pramipexole ER 5 rabeprazole 6 memantine ER 1 moxifloxacin 3 norethindrone-ethin estradiol 7 Oxbryta 1 pramoxine/HC acetate 2.5% 6 Ragwitek 1 Menactra 7 Mulpleta 1 norgestimate-ethinyl estradiol 7 oxcarbazepine 5 prascion RA 6 rajani 7 Menest 7 Multaq 2 norgestrel-ethiny estra 7 Oxervate 2 prasugrel 1 raloxifene 1 Menhibrix 7 multivitamin + fluoride (Rx-only) 7 Noritate 6 oxiconazole 3 Pravachol 2 raloxifene 4 Menomune-A-C-Y-W-135 7 mupirocin 6 norlyda 7 oxiconazole cream 5 pravastatin 2 ramelteon 4 Menopur 7 MUSE 4 norlyroc 7 Oxistat ceram 3 prazosin 2 ramipril 2 Menostar 7 my choice 7 Noroxin 3 Oxistat lotion 3 pre-natal vitamins (Rx-only) 7 Ranexa 3 Menveo A-C-Y-W-135-Dip 7 my way 7 Norpace CR 2 Oxistat lotion 5 Precision 2 ranitidine (all) 6 meperidine 4 Myalept 4 Northera 2 Oxtellar XR 5 Pred Mild 2 ranolazine ER 3 mephobarbital 5 Mycapssa 4 nortrel 7 oxybutynin 1 Pred-G 2 rasagiline 5 Mephyton 7 mycophenolate mofetil 3 nortriptyline 4 oxybutynin ER 1 prednicarbate 6 Rasuvo 5 meprobamate 4 mycophenolic acid 3 Norvir capsule, solution 3 oxycodone 5 prednisolone acetate 2 Ravicti 4 mercaptopurine 1 Mydayis 4 Nourianz 5 Oxycodone ER 5 prednisolone oral 6 Rayaldee 7 mesalamine DR capsule 400mg 6 Myleran 1 Novarel 7 oxycodone/acetaminophen 5 prednisolone sod phosphate 2 Rayos 6 mesalamine DR tablet 1.2g 6 Myrbetriq 1 Novolin 1 oxycodone/aspirin 5 prednisone oral 6 react 7 mesalamine DR tablet 800mg 6 myzilra 7 Novolog 1 oxycodone/ibuprofen 5 Prefest 7 Rebetol 3 Noxafil 3 pregabalin 5 mesalamine enema 6 N Oxycontin 5 Rebif 4 mesalamine suppository 6 Nubeqa 1 oxymorphone/ER 5 Pregnyl 6 reclipsen 7 nabumetone 5 Mesnex 1 Nucala syringe/auto-inject 5 Oxytrol 1 Premarin 7 Rectiv 6 metadate ER 4 nadolol 2 Nucynta 5 Oxytrol for Women 1 Premarin vag cream 7 Regenecare 6 metaproterenol syr 5 naftifine 6 Nucynta ER 5 Ozempic 1 Premphase 7 Regranex 6 metaxalone 4 naltrexone 4 Nuedexta 4 Ozobax 4 Prempro 7 Relenza 3 Namzaric 1 Nulytely 6 Prenate Elite 7 metformin 2 P Relistor injection 6 metformin ER (generic naphazoline 2 Nuplazid 4 Prepopik 6 Relistor tablets 6 Glucophage XR) 2 naproxen CR 375mg tablet 5 Nurtec ODT 5 Palforzia 1 Prestalia 3 Relpax 5 metformin ER (not generic naproxen/EC 5 Nutropin/AQ 4 paliperidone 4 Prevacid 6 Renagel 7 Glucophage XR) 2 naratriptan 4 NuvaRing 7 Palynziq 6 Prevacid 24HR 6 Renvela 7 metformin/glyburide 2 Narcan Nasal Spray 4 Nymalize 2 Pancreaze 6 Prevacid Solutab 6 repaglinide 2 metformin solution 2 Nasacort Allergy 24HR 1 nystatin 3 Panretin 6 previfem 7 repaglinide/metformin 2 methadone 5 Nasacort AQ 1 nystatin 6 pantoprazole 6 Prevnar 13 7 Repatha 2 methazolamide 3 Nascobal 7 nystatin vag tab 7 Paragard 7 Prevymis tablets 3 Repronex 7 methenamine combination 3 Natazia 7 nystatin/triamcinolone 6 paregoric 6 Prexxartan 2 Rescriptor 3 Methergine 7 nateglinide 2 nystop 6 paricalcitol 7 Prezcobix 3 Rescula 2 methimazole 6 Natesto 4 Nyvepria 1 paromomycin 3 Prezista 3 Restasis 2 Natpara 4 paroxetine 4 Prilosec 6 methocarbamol 4 O Retacrit 1 methotrexate 1 necon 7 paroxetine 7.5mg 7 Prilosec-OTC 6 Retevmo 1 methotrexate 5 nefazodone 4 Ocaliva 6 Pazeo 2 Primaquine 3 Revatio 3 methoxsalen capsule 6 neomycin 3 ocella 7 PCE 3 primidone 5 Revcovi 4 methyclothiazide 3 neomycin/bacitracin/poly B 2 octreotide 4 Pediatric sodium fluoride chewable abt ProAir HFA 5 Revlimid 1 methyldopa 2 neomycin/bacitracin/poly B/HC 2 Odactra 1 & drops 7 ProAir RespiClick 5 Reyvow 5 methyldopa/HCTZ 3 neomycin/polymyxin/HC otic 2 Odefsey 3 peg 3350/electrolyte 6 probenecid 2 Rexulti 4 methylergonovine maleate 7 Neoral 3 Odomzo 1 Peg-Intron 3 procainamide 2 Rhinocort Allergy 1 methylphenidate CD 4 Nerlynx 1 Ofev 5 Peganone 5 procentra 4 Rhopressa 2 Methylphenidate ER (brand) 4 Nesina 2 ofloxacin 3 Pegasys 3 prochlorperazine 6 ribapak 3 methylphenidate/SR 4 Neulasta 1 ofloxacin ophth 2 Pemazyre 1 Procrit 1 ribasphere 3 methylprednisolone 4mg, 8mg, 16mg, Neupogen 1 ofloxacin otic 2 penicillamine 5 Proctofoam-HC 6 Ribatab 3 32mg 6 Nevanac 2 ogestrel 7 penicillin VK 3 Procysbi 4 ribavirin 3 metipranolol 2 new day 7 olanzapine 4 Pennsaid 5 progesterone in oil 7 Ridaura 5 metoclopramide 6 Nexavar 1 olanzapine/fluoxetine 4 pentamidine inhal powder 3 progesterone, micronized 7 rifabutin 3 metolazone 3 Nexium 6 Oleptro ER 4 Pentasa 6 Prograf 3 Rifamate 3 metoprolol 2 Nexium 24HR 6 olmesartan 2 pentazocine/naloxone 5 Prolensa 2 rifampin 3 metoprolol ER 2 Nexium DR 10mg, 20mg, olmesartan/amlodipine 3 pentoxifylline 1 Promacta 1 Rifater 3 metoprolol/HCTZ 2 40mg packet 6 olmesartan/amlodipine/HCTZ 3 Perforomist 5 promethazine 6 riluzole 4 metoprolol/HCTZ 3 Nexium DR 2.5mg, 5mg packet 6 olmesartan/HCTZ 3 pergolide 5 promethazine/codeine 1 rimantadine 3 Metrogel topical 1% 6 Nexletol 2 olopatadine 0.2% drop 2 perindopril 2 promethazine/DM 1 Rinvoq 5 metronidazole 3 Nexlizet 2 olopatadine ophth 2 permethrin 6 promethazine/phenylephrine/ risedronate 150mg 4 metronidazole cream/lotion/ Nexplanon 7 Olumiant 5 perphenazine 4 codeine 1 risedronate DR 4 0.75% gel 6 next choice one dose 7 omega-3 acid ethyl esters 2 Pertzye 6 propafenone 2 risperidone 4 mexiletine 2 niacin ER 2 omeprazole 6 Pexeva 4 propafenone SR 2 risperidone m-tab 4 Miacalcin inj. 1 niacin IR 500mg tablet 2 omeprazole/sodium bicarbonate 6 phenazopyridine 1 propantheline bromide 6 ritonavir tablet 3 mibelas 24 fe 7 niacin (OTC) 2 Omnaris 1 phendimetrazine 7 propranolol 2 rivastigmine 1 miconazole vag supp 7 niacin/simvastatin 2 Omnitrope 4 phenelzine 4 propranolol/HCTZ 3 rivastigmine patch 1 microgestin 7 nicardipine 2 Omontys 1 phenobarbital 5 propylthiouracil 6 rivelsa 7 microgestin fe 7 Nicorelief gum 6 Omtryg 2 phenoxybenzamine 2 Protonix 6 rizatriptan 5 midodrine 2 Nicorelief lozenge 6 ondansetron 6 phentermine 7 protriptyline 4 Rocklatan 2 midodrine 3 Nicotine Gum 6 OneTouch Test Strips 2 phenylephrine ophth 2 Proventil HFA 5 Rondec DM/TR 1 miglitol 2 Nicotine lozenges 6 Onexton 6 phenytoin 5 prudoxin 6 ropinirole 5 miglustat 4 Nicotine patches various 6 Ongentys 5 philith 7 pseudoephedrine 1 ropinirole ER 5 mili 7 Nicotrol Inhaler 6 Onglyza 2 Phisohex 6 pseudoephedrine/codeine 1 rosuvastatin 2 Minitran 3 Nicotrol NS 6 Onureg 1 Phospholine Iodide 2 Pulmicort flexhaler/powder 5 Roxicet Soln 5 Minivelle 7 nifediac CC 2 Onzetra 5 phytonadione 7 Pulmicort respules (1mg/2ml) 5 Rozerem 4 Minocin 3 nifedical XL 2 opcicon one-step 7 Picato 6 Pulmozyme 5 Rozlytrek 1 minocycline 3 nifedipine 2 Opsumit 3 pilocarpine 2 Purixan 1 Rubraca 1 minocycline 6 nifedipine SR 2 option 2 7 pimtrea 7 Pylera 6 Ruconest 3

10 Section II — Index (cont’d)

DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE DRUG NAME PAGE Ruzurgi 4 stavudine 3 testosterone enanthate 4 Trikafta 5 Viibryd 4 Zelnorm 6 Rybelsus 1 Staxyn 4 testosterone gel 4 trientine 1 Vimovo 5 Zembrace 5 Rydapt 1 Steglatro 2 Testosterone gel (brand) 4 trifluoperazine 4 Vimpat 5 zenchent 7 Rytary 5 Steglujan 2 testosterone pump 4 trifluridine 2 Viokace 6 zenchent fe 7 S Stelara 6 Tetanus Diphtheria Toxoids 7 trihexyphenidyl 5 viorele 7 Zenpep 6 Stendra 4 tetrabenazine 3 Trijardy XR 2 Viracept 3 zenzedi 5mg, 10mg 4 Sabril 5 Stimate 4 tetracycline 3 Trilyte 6 Viramune, XR 3 zeosa 7 Saizen 4 Stiolto Respimat 5 Tev-Tropin 4 trimethobenzamide 6 Viread 150mg, 200mg, 250mg, Zepatier 3 salsalate 5 Stivarga 1 Thalomid 1 trimethoprim 3 40mg/scoop powder 3 Zeposia 4 Samsca 15mg 3 Strensiq 1 Theo-24 5 trinessa 7 vit A,D,C + fluoride (Rx-only) 7 Zerviate 2 Samsca 30mg 3 Striant 4 theochron 5 trinessa lo 7 vit A,D,C + fluoride and iron Zetonna 1 Sanctura 1 Stribild 3 theophylline/SR tabs, liquid 5 Trintellix 4 (Rx-only) 7 Ziagen 3 Sanctura XR 1 Striverdi Respimat 5 thioridazine 4 Triumeq 3 Vitekta 3 Ziana gel 6 Sancuso 6 Subsys 5 thiothixene 4 trivora 7 Vitrakvi 1 Ziextenzo 1 Sandimmune 3 Sucraid 6 thyroid 6 Trokendi XR 5 Vituz 1 zidovudine 3 Sandostatin 4 sucralfate 6 Thyroid (Armour) 6 tropicamide 2 Vivlodex 5 zileuton ER 5 Saphris 4 sulfacetamide 10% 2 Thyrolar 6 trospium 1 Vizimpro 1 Zioptan 2 sapropterin 6 sulfacetamide/prednisolone ophth 2 tiagabine 5 trospium ER 1 Vogelxo 4 ziprasidone caps 4 Sarafem 4 sulfamethoxazole/trimethoprim 3 Tibsovo 1 TRUEtest 2 voriconazole 3 Zipsor 5 Savaysa 1 sulfasalazine 6 ticlopidine 1 TRUEtrack 2 Vosevi 3 Zmax 3 Savella 4 sulfasalazine EC 6 Tiglutik 4 Trulance 6 Votrient 1 Zocor 2 Saxenda 7 sulindac 5 tilia fe 7 Trulicity 1 Vraylar 4 Zohydro ER 5 scopolamine patch 6 sumatriptan 5 timolol 2 Trumenba 7 Vumerity 4 Zolinza 1 Secuado 4 Sumavel 5 timolol 2 Truvada 3 vyfemla 7 zolmitriptan 5 Seebri 5 Sunosi 4 tinidazole 3 Tudorza 5 Vyleesi 7 zolpidem 4 Segluromet 2 Suprenza ODT 7 Tirosint 6 tulana 7 vylibra 7 zolpidem ER 4 selegiline 5 Suprep 6 Tivicay 3 Turalio 1 Vyndamax 3 zolpidem ER sublingual tablet 4 selenium sulf 2.5% suspension 6 Sutent 1 Tivorbex 5 Tybost 3 Vyndaqel 3 Zolpimist 4 Selzentry 3 syeda 7 tizanidine 4 tydemy 7 Vyvanse 4 Zomig 5 Semglee 1 Sylatron 1 Tobi 3 Tykerb 1 Vyzulta 2 Zomig Nasal 5 Semprex-D 1 Symbicort 5 Tobi Podhaler 3 Tylenol/codeine 5 W Zomig ZMT 5 Sensipar 4 Symdeko 5 Tobradex ointment 2 Tymlos 4 Zonalon 6 Serevent Diskus 5 Symfi 3 Tobradex ST 2 Tyvaso 3 warfarin 1 zonisamide 5 serophene 6 Symfi Lo 3 tobramycin ampule/neb 3 Tyzeka 3 Wakix 4 Zokinvy 4 Serostim 4 wera 7 Symjepi 5 tobramycin soln 2 U Zontivity 1 sertraline 4 Symlin 1 tobramycin/dexameth 2 Winlevi 6 Zontivity 1 setlakin 7 Sympazan 5 Tobrex ointment 2 Ubrelvy 5 wixela inhub 5 Zorbtive 4 sevelamer 7 Symproic 6 Tobrex solution 2 Uceris 6 wymzya fe 7 Zortress 3 Seysara 6 Synarel 4 Today Contraceptive Sponge 7 Udenyca 1 Wynzora 6 Zostavax 7 sharobel 7 Syndros 6 tolazamide 2 Ukoniq 1 X zovia 7 Shingrix 7 Ulesfia 6 Synjardy 2 tolbutamide 2 Xadago 5 Zubsolv 4 Signifor 4 Synjardy XR 2 tolcapone 5 Ultresa 6 zumandimine 7 sildenafil 20 mg tab 3 unithroid 6 Xalatan 2 Synribo 1 tolmetin 5 Xalkori 1 Zuplenz 6 sildenafil citrate 25mg, 50mg, Synthroid 6 Tolsura 3 Upneeq 2 Zurampic 2 100mg 4 Uptravi 3 Xarelto 1 T tolterodine 1 Xartemis XR 5 Zyban 6 sildenafil suspension 3 tolterodine ER 1 Urecholine 1 Zydelig 1 Silenor 4 Tabrecta 1 ursodiol 6 Xatmep 1 tolvaptan 3 Xcopri 5 Zyflo 5 Siliq 6 Taclonex 6 topiramate 5 Utibron 5 Zykadia 1 silodosin 4 tacrolimus 3 Xeljanz 5 topiramate ER 5 V Xeljanz XR 5 Zylet 2 silver sulfadiazine 5 tacrolimus 6 torsemide 3 Zypitamag 2 valacyclovir 3 Xelpros 2 simliya 7 tadalafil (generic Adcirca) 3 Tosymra 5 Zyprexa 4 Valchlor 1 Xembify 4 simpesse 7 tadalafil (generic Cialis) 4 Toujeo 1 Zyprexa Zydis 4 valganciclovir solution 3 Xenical 7 Simponi 5 Tafinlar 1 Toviaz 1 Zytiga 1 valganciclovir tablets 3 Xepi 6 simvastatin 2 Tagrisso 1 Tracleer tab 3 valproic acid 5 Xermelo 6 sirolimus 3 Takhzyro 3 Tracleer tab for susp 3 valsartan 3 Xgeva 1 Sirturo 3 Taltz 6 Tradjenta 2 valsartan/HCTZ 2 Xhance 1 Sitavig 3 Talzenna 1 tramadol ER capsule 5 Valtrex 3 Xifaxan 3 Sivextro 3 tamoxifen 1 tramadol/acetaminopen 5 Vancocin 3 Xigduo XR 2 Sklice 6 tamsulosin 4 tramadol/ER tablet 5 vancomycin caps 3 Xiidra 2 Skyla 7 Tanzeum 1 trandolapril 2 vandazole vag 7 Ximino 6 Skyrizi 6 Tarceva 1 trandolapril/verapamil 3 vardenafil 4 Xofluza 3 Slynd 7 Targretin gel 1 tranylcypromine 4 vardenafil ODT 4 Xopenex HFA 5 sod. polystyrene sulfonate 5 tarina 24 Fe 7 Travatan Z 2 Varubi 6 Xospata 1 sod. sulfacetamide/sulfur emulsion tarina fe 7 travoprost (generic Travatan Z) 2 cleanser 6 Vascepa 2 Xpovio tarina Fe 1-20 eq 7 trazodone 4 sod. sulfacetamide/sulfur lot 6 VCF 6 Xtampza ER 5 Tasigna 1 Trelegy Ellipta 5 sodium chloride irrigating soln 5 Vecamyl 3 Xtandi 1 Tavalisse 1 Tremfya 6 sodium phenylbutyrate 4 veletri 3 Xtoro 2 Taytulla 7 Tresiba 1 sodium sulfacetamide 6 velivet 7 xulane 7 tazarotene cream 6 tretinoin cr/gel 6 Sofosbuvir/Velpatasvir 3 Velphoro 7 Xultophy 1 Tazorac gel 6 tretinoin microsphere 6 solifenacin 1 Veltassa 4 Xuriden 4 Tazverik 1 Trexall 1 Soliqua 1 Veltin gel 6 Xyosted 4 Tecfidera 4 Treximet 5 Solodyn 6 Vemlidy 3 Xyrem 4 Tegretol 5 Trezix 5 Somatuline Depot 4 Venclexta 1 Xywav 4 Tegretol XR 100mg 5 tri femynor 7 Somavert 4 venlafaxine 4 Tegsedi 4 tri-estarylla 7 Y Somnote 4 venlafaxine ER 4 Tekturna 3 tri-legest fe 7 Yonsa 1 Sonata 4 Ventavis 3 Tekturna HCT 3 tri-linyah 7 Yosprala 5 Soolantra 6 Ventolin HFA 5 telmisartan 2 tri-lo-estarylla 7 Yupelri 5 sotalol 2 verapamil/SR 2 telmisartan/amlodipine 3 tri-lo-marzia 7 yuvafem 7 sotret 6 Verquvo 3 telmisartan/HCTZ 3 tri-lo-mili 7 Sovaldi 3 Versacloz 4 temazepam 4 tri-lo-sprintec 7 Z Spectracef 3 Verzenio 1 Temodar 1 tri-mili 7 Zaditor 2 spinosad 6 vestura 7 temozolomide 1 tri-previfem 7 zafirlukast 5 Spiriva 5 Viagra 4 Tepmetko 1 tri-sprintec 7 zaleplon 4 Spiriva Respimat 5 Vibramycin 3 Tenivac 7 Tri-Vi-Flor 7 zarah 7 spironolactone 3 Vicodin/ES 5 tenofovir 300mg 3 tri-vylibra 7 Zarxio 1 spironolactone/HCTZ 3 Victoza 1 terazosin 2 tri-vylibra lo 7 Zavesca 4 Sporanox suspension 3 Victrelis 3 terbinafine 3 triamcinolone acetonide 6 Zecuity 5 sprintec 7 Videx 3 terbutaline tab 5 triamcinolone nasal spray 1 Zegerid 6 Sprix 5 Viekira 3 terconazole 7 triamcinolone spray 6 Zegerid OTC 6 Sprycel 1 vienva 7 Testim 4 triamterene/HCTZ 2 Zejula 1 sronyx 7 vigabatrin oral powder 5 testosterone cypionate 4 triazolam 4 Zelboraf 1

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